Ophthalmology and Optometry Coding Alert

Ocular photodynamic therapy (OPT), 67221, is used to treat the classic form of wet macular degeneration but if you don't know what components of OPT you can report, don't expect to be showered with reimbursements. OPT is a noninvasive treatment for age-related macular degeneration that relies on the ability of a photoactive drug to destroy the degenerated cells targeted by the laser. But there are a number of components of OPT that are not included in 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]). Ask yourself the following three questions when coding OPT from start to finish to be sure your claims are appropriately reimbursed. Code Bilateral 92235 Based on Documentation The first question you should ask yourself when coding OPT is, Did the ophthalmologist order fluorescein angiography to be taken on one or both eyes? Prior to determining whether a patient is a candidate for OPT, ophthalmologists have to confirm that the patient's macular degeneration is "wet," determined using fluorescein angiography (FA), 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report). When fluorescein angiography is performed, it is not uncommon for the photographs of both the eye in question and the fellow eye to be taken regardless of whether macular degeneration is present in the fellow eye, says Ilan Hartstein, MD, a practicing ophthalmologist with La Palma Eye Care Center in California. This can sometimes be a tricky situation because coding FAbilaterally depends on what was ordered by the ophthalmologist and what the ophthalmologist has documented.

In the Medicare program, FA code 92235 is considered a unilateral code, Roxanne Oyler, CPC, business supervisor for Kentucky Eye Care in Louisville warns coders.
This means that if photographs are taken of both eyes, and there is evidence that both photographs were medically necessary, you will receive additional payment for a second FA. It also means that "you will need to use either modifier -50 (Bilateral procedure) or the alpha modifiers -RT and -LT if FAis taken for both eyes," she says. For example, an ophthalmologist orders FA photos for a patient with edema in both eyes, 362.83 (Other retinal disorders; retinal edema). The bilateral edema constitutes medical necessity for billing bilateral FA: 92235-50, or 92235-RT and 92235-LT on separate lines. Carriers are very specific about how they want bilateral FA billed some may not recognize modifier -50, and others won't recognize the bilateral FA if it is billed on one line, Oyler says. "So be sure to check with your local carrier for their preferred method of billing bilateral FA."

If you do use the -50 modifier on one line, be sure to double your fee and check the Explanation of Medicare Benefits [...]