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 physician during the postoperative period. There are three types of procedures which would call for a modifier -58: (1) a procedure that was planned prospectively at the time of the original procedure (staged); (2) a procedure that is more extensive than the original procedure; or (3) a procedure which is done as therapy following a diagnositc surgical procedure. According to Roberts, trabeculoplasty and iridotomy are related procedures and the second procedure fits the parameter of a greater surgical procedure following a lesser surgical procedure, so the -58 modifier applies.

But in the case of an iridotomy following a
trabeculoplasty, the modifier -78 would apply if the diagnosis for both procedures is glaucoma, she explains. This is because this scenario does not fit any of the three applications for the -58 modifier. And modifier -79 would only be used if the two procedures were not both performed on the same eye, Roberts adds.

The -58 modifier is like -79 in that the full Medicare fee schedule applies to it instead of the reduced amount applied by -78, she explains. Because both the -58 and the -79 modifiers get the full Medicare fee schedule, which is a global payment including postoperative care, a new 90-day postoperative time frame begins with the second surgery. This means that the old post-op period and the new post-op period run concurrently. So you dont add 90 days onto the remaining post-op days from the first surgery. The -78 modifier generates a reduced Medicare fee schedule which does not include payment for postoperative days. So you remain under the original 90-day post-op period of the first procedure.

Lets say both procedures are done in the left eye. If the trabeculoplasty is done first, you would code the procedures this way: 65855-LT for the first surgery, and 66761-78-LT for the second surgery. If the trabeculoplasty is done second, code the procedures this way: 66761-LT for the first surgery, and 65855-58-LT for the second.