Ophthalmology and Optometry Coding Alert

Confusion about coding epilation for trichiasis can be a thing of the past if you can keep up with your modifiers.

Epilation for trichiasis 67820* (Correction of trichiasis; epilation, by forceps only) and CPT 67825* ( epilation by other than forceps [e.g., by electrosurgery, cryotherapy, laser surgery]) the removal of uncomfortable misdirected eyelashes that grow in toward the eyeball, can be a difficult procedure to code because different carriers demand different methods of billing. Coding epilation becomes even more daunting if your physician completes the procedure bilaterally or on multiple eyelids, or if more than one eyelash is removed.

How can coders keep epilation billing straight and ensure proper reimbursement? The first step to correct coding is to determine your payer's accepted billing method. There are three methods of billing epilation per eye, per eyelid, and per lash and your payer will only reimburse you for claims submitted by one of these methods.

Typically, private payers consider billing per eye to be the correct way to handle epilation coding. In contrast, some Medicare carriers, such as Noridian Mutual of Arizona, pay by the eyelid. And on a rare occasion, you may come across a carrier with an LMRP that allows for billing for each lash. I always recommend that you check with your local payer representative and ask for their filing guidelines on this procedure" " says Sherry Searson CPC an independent coding consultant based in Charleston S.C. "This will reduce your denials and save time and money on refiling denied claims."

Regardless of the method you must use to garner reimbursement for epilation you must document an ICD-9 code that signals to Medicare that the procedure was performed out of medical necessity. Acceptable diagnosis codes will vary among carriers but some ICD-9 codes that typically support medical necessity include 374.01 Senile entropion; 374.04 Cicatricial entropion; 374.05 Trichiasis without entropion; 374.54 Hypertrichosis of eyelid; and 374.89 Other disorders of eyelid.

Method 1: Code Per Eye

If the carrier pays per eye you should use the correct epilation code 67820 or 67825 with the correct eye modifier -RT or -LT or modifier -50 (Bilateral procedure) if performed bilaterally.

Procedure codes 67820 and 67825 are designated bilateral indicator "0" codes by the 2002 National Physician Fee Schedule. The "0" indicates that bilateral rules do not apply (to 67820 and 67825) because of physiology or anatomy or because the code description specifically states that it is a unilateral code. Therefore bilateral modifier -50 is not a viable option for indicating epilation of lashes on both eyes.

However epilation codes 67820 and 67825 have a multiple-procedure indicator of "2" that indicates standard payment adjustment rules for multiple procedures apply. In other words modifier -51 (Multiple procedures) can be used to designate epilation of multiple lashes of an eye which is why the bilateral epilation in the example above was coded with modifier -51 in addition to -RT and -LT rather than 67820-50-51.

For example your carrier has a local medical review policy that allows billing by eye and your physician by use of forceps removes one lash from a patient's left lower eyelid and two lashes from the same patient's right upper eyelid. You should code 67820-50 if the carrier is Medicare and 67820-LT 67820-50-RT for private carriers.

Method 2: Code Per Eyelid

If you are submitting a claim to a carrier that permits billing by eyelid you have twice as many modifiers (and twice the number of reimbursement possibilities) than when billing epilation per eye.

The eyelid modifiers you should use are -E1 (Upper left eyelid) -E2 (Lower left eyelid) -E3 (Upper right eyelid) and -E4 (Lower right eyelid).

For example a patient presents with trichiasis of two lashes of her upper left eyelid one lash of her lower left eyelid and one lash of her lower right eyelid. The severity of the irritation to the patient's eyes constitutes medical necessity for removing the lashes. The physician performs epilation of all the lashes using laser surgery. The procedures should be coded 67825-E1 67825-51-E2 67825-51-E4.

The multiple-procedures modifier -51 is used here to indicate that lashes were removed from multiple eyelids. As for payment you are allowed the full fee for the first line billed and 50 percent of the fee schedule for the second and third lines billed greater reimbursement than if you employ CPT's coding-per-lash guidelines.

Billing per lid has been met with varied response says Linda Abel CPC assistant administrator at the Hauser-Ross Eye Institute in Sycamore Ill. "Our Medicare carrier (WPS for Illinois) responds that they do not allow 'this many services in this time period ' " she says. But billing per eye has not received a warm welcome either local carrier variations strike again!

Method 3: Code Per Lash

On the rare occasion when your carrier's epilation LMRP allows you to code by lash use your knowledge of the local lash modifiers to wow your fellow coders.

The lash modifiers begin with -Y2 for the first lash removed and continue to -Y9 for the eighth. For lashes nine and 10 use -Z2 and -Z3 respectively. You should then append modifier -99-U2 for the 11th lash as well as any additional lashes (-99 Multiple modifiers).