Ophthalmology and Optometry Coding Alert

Test your FBR, Epilation & YAG coding know-how.

These are the top three questions missed on the OCS exam, according to AAO’s Jennifer Edgar, OCS, who conducted an Ophthalmic Coding Specialist prep course at 2016’s annual conference. How do you measure up?

Most Missed Question #1:

A patient with commercial insurance had several corneal foreign bodies removed from the left eye. CPT^® codes 65222-LT (FB removal) and 92071-LT (CL fitting for ocular disease) were submitted. Payment for 92071 was denied. You should:

     A. Charge the patient for 92071.
     B. Resubmit 92071-59-LT
     C. Write off 92071 due to CCI edits and bill patient for bandage lens.
     D. Appeal the denial.

Answer: This claim likely was denied because some payers include the wound dressing (in this case, the bandage lens) in the value of 65222 (Removal of foreign body, external eye; corneal, with slit lamp). Because of that, you would not be able to charge the patient for the fitting. You could, however, charge them for the lens itself (as long as it is a revenue lens for you, and not a trial or sample lens). Option C is the answer.

Most Missed Question #2: When epilating lashes (senile) on all four lids, which of the following options should be submitted with CPT^® code 67820?

     A. Modifier 51.
     B. Modifiers E1, E2, E3, E4.
     C. Modifiers RT and LT.
     D. No modifiers, as payment is per session.

Answer: There are multiple ways to code epilation, depending on the payer, but this question doesn’t tell us who the payer is (e.g., private or Medicare), so you’ll have to use the process of elimination to get to the right answer.

Payers pay for epilation per eye, per lid, or sometimes per lash, but they no longer pay per session — you can eliminate option D.

Modifier 51 indicates multiple procedures, but simply appending modifier 51 to the procedure code isn’t enough. You’d still need to code to the highest level of specificity by indicating either the lid or the eye, so you can eliminate option A.

For a payer that allowed you to bill by the lid, you could indeed use the eyelid modifiers. However, you would also need to append modifier 51 to indicate the same procedure was performed on different sites. That’s not a choice here, so you can eliminate option B.

Option C is the correct answer.

Note: For billing Medicare, you’d list the procedure on a single line using modifier 50 (to indicate a bilateral procedure) and a quantity of 1 (the bilateral indicator for code 67820).

Most Missed Question #3: A patient with commercial insurance underwent a YAG capsulotomy on the left eye the same day as cataract surgery was performed on the right eye. This was done as a convenience for the patient. What modifier(s) should be appended to the YAG code?

     A. 59, LT
     B. 79, LT
     C. LT
     D. 59, XS, and LT

Answer: Since multiple procedures were performed on the same day and during the same surgical session, your first instinct should be to check for any bundled codes according to Correct Coding Initiative (CCI) edits. You’ll note that YAG and cataract procedures are bundled. They also have an indicator of 1, which means they can be unbundled in certain circumstances using modifier 59 (Distinct procedural service).

When is it appropriate to unbundle? When you want to identify that the procedures were “distinct” from other services performed on the same day, and thus receive payment for both. Typically, ‘distinct’ means performed on a different site or organ system, in a different session, different incision, etc.

Note: Just because you unbundle two codes doesn’t mean you’ll get fully reimbursed for each. A multiple procedure discount may still apply.

Since the YAG and the cataract procedures were performed on different eyes, you must append modifier 59 to unbundle. You can eliminate options B and C.

Now, take a look at your payer-specific guidelines. Medicare introduced modifier XS (Separate structure) in 2015 along with XE, XP, and XU. The X modifiers are more specific iterations of modifier 59, and are not to be used in conjunction with 59. Commercial payers don’t recognize modifier XS, so you can eliminate option D. Option A is the correct answer.

Why 59 instead of 79? Some coders would be tempted to append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period). After all, the YAG and the cataract surgery are unrelated, and you would be within the global period. If those codes weren’t bundled, that strategy would be correct. This is a prime example of why you should consult the CCI edits every time you have multiple procedures. These edits are updated quarterly, so be sure to check frequently for updates.