Ophthalmology and Optometry Coding Alert

In the November 1999 issue of Ophthalmology Coding Alert, we answered a reader question about how to code for forced ductions without anesthesia. The code for forced ductions specifically includes anesthesia. The descriptor for 92018 is: ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete. The answer to the reader question recommended using the -52 modifier (reduced services) on 92018 if you do the procedure without anesthesia. It also said that forced ductions are almost always done under general anesthesia; the exception is pediatrics.

Larry P. Frohman, MD, Associate Professor of Ophthalmology and Neurosciences at UMDNJ-New Jersey Medical School, contacted us with two main concerns about that answer. He notes that forced ductions are not always done under general anesthesia. In the world of ophthalmology, many cases are tested in the exam chair simply under topical anesthesia, he says. Although it is true that many pediatrics cases are done under general anesthesia, when one has a cooperative child, particularly with older children, one may certainly attempt to do the case under topical anesthesia and spare the risk of general anesthesia.

Frohman also is concerned about the use of the -52 modifier when the forced duction is done without general anesthesia. Yes, the -52 modifier is for reduced services, but the use of the -52 modifier provides a means of reporting reduced services without disturbing the identification of the basic service, according to CPT. Here, the basic service is for an ophthalmological examination and evaluation, under general anesthesia, notes Frohman. The code says you may or may not do manipulation of the globe as part of the service, which means the forced ductions are not part of the basic service, whereas the general anesthesia component is. I would be concerned that users of this modifier, when general anesthesia is not part of the service, are exposing themselves to fraud charges, as the basic service itself is indeed changed, not just reduced.

We regret any confusion the answer to the reader question may have caused and hope that the following information will clarify it for our readers.

Forced Ductions Explained

As a procedure that might require general anesthesia but can be done under topical anesthesia, what exactly is a forced duction? Frohman describes the procedure in the following way:

A forced duction, sometimes called passive duction, is a test used to identify the cause of the lack of rotation of a muscle from two possible broad causes. In weakness of the muscle or paresis of the nerve supplying the muscle, the eye does not rotate as it should because, ultimately, the muscle is not contracting properly. In mechanical causes of lack of rotation of the eye, the muscle receives input instructing it to contract and rotate the eye, but mechanical forces are preventing the eye from moving properly. Two classic causes of mechanical restriction are thyroid eye disease, where the swollen muscle opposite the muscle being tested acts as a load or resistance upon the eye, preventing rotation, and in orbital fractures with entrapment, where a piece of bone or break in the bone may trap a muscle, preventing rotation of the eye.

The forced duction test is the test used to differentiate these causes. In the exam chair, it is performed by topically anesthetizing the eye with drops, and then further anesthesia may be given by soaking an applicator with topical anesthetic and applying it to the intended point of contact with the eye. Classically, a forceps is used to perform the test, by grabbing the eye and mechanically rotating it while the patient looks in the direction of gaze being tested, and seeing if the examiner can rotate the eye for the patient. Free rotation implies that the eye is not mechanically resisted, which means the rotation problem is a paresis of the nerve supplying the muscle the impulse to contract. If there is mechanical resistance, often not only does the eye not fully rotate in the direction being tested, but the examiner may feel the resistance. Some examiners prefer to do the test by pushing the globe in the intended direction with an applicator, rather than grabbing the eye with a forceps, but the overall concept is the same.

92060 a Possible Code

Frohman raises the issueagainof how to bill for forced ductions in an office setting without general anesthesia. Generally, as I perform my forced ductions as part of an overall evaluation of motility, I am performing code 92060 (sensorimotor examination with multiple measurements of ocular deviation [e.g., restrictive or paretic muscle with diplopia] with interpretation and report [separate procedure]) on top of my ophthalmologic examination or consultation. If I did a forced duction in the exam chair, I would likely include this under code 92060.

If, in fact, a provider did only forced ductions and no multiple measurements of the ocular deviation, then 92060 would not apply, explains Lise Roberts, vice president of Health Care Compliance Strategies based in Syosset, N.Y. Because the eye is anesthetized locally for forced ductions, the procedure cannot be considered a sensory examination, she says. In this event, the service would be handled like any other ophthalmic testing service that does not have a code specifically for it. It would be included in the evaluation and management (E/M) level of care or eye exam code as part of the overall work in the visit.

The definition of 92060 is precisely sensorimotor examination with multiple measurements of ocular deviation, notes Roberts, explaining that multiple measurements must be done. If a physician does forced ductions as part of an overall evaluation of motility, that means the physician is doing multiple measurements. You could not use 92060 when only forced ductions are done and no multiple measurements are takenor you would indeed have to use the -52 modifier, Roberts notes. Multiple measurements do have to be documented. I know from seeing audits that auditors look for the measurements.