Ophthalmology and Optometry Coding Alert

Patients with serious glaucoma may need several
operations. When these are done in the postoperative period, the ophthalmologist needs to use a modifier in order to get reimbursed. Phillip Calenda, MD, of the Tarboro Clinic Eye Center in Tarboro, NC, writes to ask in particular how to bill 65855 (trabeculoplasty by laser surgery) followed by 66761 (iridotomy/iridectomy by laser surgery), and also how to bill 66761 followed by 65855. In both Calendas cases, the second procedure is done in the same eye as the first. Our sources recommend using modifier -78, or modifier -79 if circumstances call for it. Modifier -78 (a return to the operating room for a related procedure during the postoperative period) will yield a lower reimbursement for the second procedure than modifier -79 (unrelated procedure or service by the same physician during the postoperative period).

I would use modifier -78 if its in the same eye, if its a Medicare patient, says Carol Washington, patient accounts manager for Nevyas Eye Associates, an eight-ophthalmologist practice in Bala Cynwyd, PA. Because both procedures are done for a type of glaucoma, Washington, who bills for one ophthalmologist who specializes in glaucoma, would say that they are related and, therefore, they fall under the -78 modifier.

But there are times when the modifier -79 would be
more appropriate, according to Libby Kuntz, administrator for the Ophthalmology Center Limited, a three-
ophthalmologist, one-optometrist practice in Philadelphia, PA. I would use a modifier -79 because its not the same procedure, says Kuntz, who is basing her decision on 20 years of experience in ophthalmology practice administration. I dont consider them even related procedures, she says. And she believes the reason for the second procedure is important as well. For example, if a glaucoma attack is the reason for the second procedure, that would warrant a modifier -79, says Kuntz.

The best way to decide which modifier to use is to ask the surgeon, experts advise. If the second surgery is for the same condition, then you have to use modifier -78. If the patient has glaucoma, and they have glaucoma surgery, and its in the same eye, that would probably have to be a modifier -78. If its the same diagnosis, it would definitely be related. But always ask the physician, just to be sure.

So, which modifier should you use when both
procedures are performed in the same eyemodifier -78, or modifier -79? If the trabeculoplasty follows the iridotomy, the correct modifier would actually be -58, says Lise Roberts, vice president of Health Care Compliance Strategies and an ophthalmology coding specialist, based in Syosset, NY. The definition of modifier -58 is staged or related procedure or service by the same [...]