Ophthalmology and Optometry Coding Alert

Forgetting modifier -50 could cost your practice $66 for each angiography

Your ophthalmologist performs fundus photography (FP) and fluorescein angiography (FA) on both eyes of a glaucoma patient. You code 92250 and 92235, and append modifier -50 (Bilateral procedure) to both. Mission accomplished, right?
 
Not quite. Even though 92250 (Fundus photography with interpretation and report) often occurs alongside 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report), the two codes have different rules for bilateral coding.
 
In Medicare's 2005 Physician Fee Schedule, 92250 has a Bilateral Surgery Indicator of "2." CMS assumes that this procedure is inherently bilateral - the reimbursement for one code includes the work done in photographing both eyes.
 
If the ophthalmologist performs 92250 on both eyes, report the code without a modifier, says Jacqueline Arriola, CPC, coder for Yuma Eye Associates in Arizona. If, however, he only performs the procedure on one eye, append modifier -52 (Reduced services) to 92250, followed by modifier -RT (Right side) or -LT (Left side) as appropriate.
 
Code 92235, however, has a bilateral indicator of "3," meaning Medicare has set the value of that code for the work done on only one eye. If the ophthalmologist performs 92235 on both eyes, you should code it bilaterally with modifier -50 - but only if you have documented medical necessity for both eyes, and the test was specifically ordered for both eyes.
 
Example 1: An ophthalmologist performs FP and FA bilaterally. Report 92235-50 and 92250.
 
Example 2: An ophthalmologist performs FP bilaterally and FA on the right eye. Report 92235-RT and 92250.
 
Example 3: An ophthalmologist performs FA bilaterally and FP on the right eye. Report 92235-50 and 92250-52-RT.
 
Example 4: An ophthalmologist performs FA and FP, both on the right eye only. Report 92235-RT and 92250-52-RT.
 
Hidden trap: When coding 92235-50 bilaterally on one line, be sure that the ICD-9 code reported with the test has been documented for both eyes, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif. If the physical examination and interpretation of the FA documents two different diagnoses, report 92235-RT and 92235-LT linked to the appropriate ICD-9 codes.
 
Example: The ophthalmologist finds dry age-related macular degeneration (ARMD) in the right eye and wet ARMD in the left. Report 92235-RT linked to 362.51 (Nonexudative senile macular degeneration) and 92235-LT linked to 362.52 (Exudative senile macular degeneration).