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Ophthalmology and Optometry Coding Alert

Coding IOL Masters and A-Scans Together? Read This First

Published on Sun Jan 09, 2005

Tricky technical and professional components could cost you $86 per patient

When your ophthalmologist plans to perform cataract extraction with intraocular lens implant (IOL) insertion, he must perform either an A-scan or an IOL Master measurement to determine the type and power the IOL should be. But some clinical circumstances might require him to do both tests on one patient - and an National Correct Coding Initiative bundle presents a coding conundrum.

Our experts show you how to steer clear of payer problems when reporting these pre-IOL insertion services by heeding the NCCI edits while still maximizing your reimbursement.

Master the Rules for -TC and -26

Partial coherence interferometry (92136, Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) done with an IOL Master device is a more advanced way of calculating IOL power than the A-scan (76519, Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation). Ophthalmologists who have an IOL Master generally prefer it to the A-scan for IOL measurements.

However, there are cases (such as mature cataracts) that require ultrasound echography. For some patients, an ophthalmologist might even have to perform both tests - if he can't get a viable result in one eye from the IOL Master, he would do an A-scan in that eye instead.

Both 76519 and 92136 are divided into two components - the technical component, marked by appending modifier -TC (Technical component), and the professional component, which you indicate with modifier -26 (Professional component).

The Medicare National Physician Fee Schedule Relative Value file assigns CPT codes modifier indicators that determine how Medicare reimburses codes that are reported bilaterally.

Experts warn: The technical component of both 76519 and 92136 is marked with modifier indicator "2," which means that the codes are considered inherently bilateral.

The work for performing the procedure on both eyes is included in the single CPT codes - you should report 76519-TC or 92136-TC only once, whether one or both eyes are examined.

The professional components (76519-26 and 92136-26) are marked with modifier indicator "3," however, which means that the codes are inherently unilateral, says Elizabeth Borgen, billing specialist for the North Dakota Eye Clinic and Surgery Center in Grand Forks. This is because the technical component of the procedure - the actual measurement of the eye - is typically performed on both eyes at the same day, she says. The ophthalmologist may, however, only perform the professional component - the IOL power calculation - on the eye that he's going to operate on.

Billing one unit of 76519 or 92136, therefore, includes:
 

  •  the technical work involved in measuring both eyes, and
     
  •  the professional work involved in IOL power calculation for one eye.

    Watch for Doctors Doing Both Tests at Once

    The difference in bilateral status between -TC and  -26 could lead to problems for ophthalmologists who need to perform both 76519 and 92136 in one sitting, says Priscilla Arnold, MD, president of the American Society of Cataract and Refractive Surgery. In an October 2004 letter to carriers, Arnold cited the example of a cataract patient undergoing an IOL Master prior to cataract surgery.

    "The ophthalmic technician begins by performing the technical component of the IOL Master on the first eye,"  Arnold says. "The test provides a viable result. The technician then moves to the second eye but discovers that the laser light is unable to reach the back of the eye and produce a viable result."

    In that case, Arnold says, it would be necessary to perform an A-scan in addition to the IOL master. After the technician performs the technical component of the A-scan on the second eye, he gives the results from both the A-scan and the IOL Master to the ophthalmologist for review. The ophthalmologist performs the professional component of the IOL Master on the eye planned for surgery.

    Snag: Coders are forbidden from accurately coding this scenario, Arnold says. ASCRS maintains that ideally, accurate coding of the above scenario would be:
     

  •  92136-TC-52 (... reduced services) for the technical component of the IOL Master performed on one eye (appending modifier -52 to show that the ophthal-mologist did not perform the full bilateral procedure)
     
  •  76519-TC-52 for the A-scan technical component performed on the other eye
     
  •  92136-26 for the IOL professional component performed on the eye planned for surgery.

    Reality: This coding combination would be rejected, Arnold says, due to a NCCI edit. To rectify this situation, Arnold and the ASCRS are lobbying Medicare administrator AdminaStar Federal to change the edit to allow coders to report both 92136 and 76519 in certain cases.

    Bow to the NCCI Edits

    NCCI declares 92136 mutually exclusive from 76519. The "0" modifier indicator means that Medicare will never reimburse for both codes reported separately during the same visit, so don't try to receive payment for each by appending a modifier.

    When two mutually exclusive codes are reported together, Medicare will only reimburse for the code in Column 1 of the NCCI edits, Borgen says. If you report the two codes together, or even just the technical or professional components of both, Medicare will only reimburse you for 92136.

    "Under the current NCCI system, CPT codes are not bundled based on their technical and professional component, but rather on their global component," Arnold says. "This flaw poses a significant problem for ophthalmologists who are performing diagnostic tests that have a technical and professional component, as well as different bilateral modifier indicators assigned within a given CPT code."

    The result? Ophthalmologists may not be "reimbursed fairly for the services they provide to Medicare beneficiaries," Arnold says.

    What to do: You would bill one unit "one or the other full code, just like if you had done both eyes," says Vivian Passaro, CPC, compliance manager at the Bascom Palmer Eye Institute at the University of Miami School of Medicine. "Since [the technical components of both codes] are bilateral, it doesn't really matter."

    Since 92136 is not only the Column 1 code but also worth more relative value units in Medicare's fee schedule (92136 has 2.27 RVUs, while 76519 has 2.17), for scenarios like the one above report 92136 once with no modifiers.

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