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 [...]