Ophthalmology and Optometry Coding Alert

Coordinate coding with the other physician or prepare for a slew of denials

When an ophthalmologist and optometrist co-manage a patient's case, you may be tempted to automatically apply modifier 54 or 55, depending on your ophthalmologist's work. If you're not careful, however, you could be triggering a red flag with Medicare and your other payers.

Key points: Make sure you append a co-management modifier only when both physicians share the patient's care, and ensure that you're performing the co-management service for the patient's benefit, not for the practice's financial benefit. Make sure your physician documents the reason for this approach to providing shared care in the medical record prior to the surgery, as well as the patient's request for, understanding of and agreement to this care plan.

You should append modifier 54 (Surgical care only) to the procedure code when the surgeon provided only the surgical portion of a CPT code, says Regan Bode, CPC, CPC-EM, ACS-EM, OCS, product manager for Custom Coding Books in Seattle and founder of Eyecoding.net. When you attach modifier 54, you're telling your carrier that the ophthalmologist performed the surgical procedure but not the preoperative and/or postoperative services.

Note: Medicare includes the service's preoperative reimbursement in the payment to the physician who performed the surgery. Medicare does not recognize modifier 56 (Preoperative management only), says Maggie M. Mac, CMM, CPC, CMSCS, CCP, ICCE, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

If your ophthalmologist is performing only a procedure's postoperative portion, you should append modifier 55 (Postoperative management only) to the procedure code.

How it works: "Most surgical CPT codes are broken down into a 10/70/20 split," Bode says "This means, of the total allowable for the CPT code, 10 percent is allocated for preoperative work, 70 percent for the surgical portion, and 20 percent for postoperative work." (Note that these percentages are only averages, and CPT code inter-service values may vary.)

Example: Your ophthalmologist performs cataract surgery for a patient who lives in a rural area and then sends the patient back to his local optometrist for post-op care. You should report the surgical code -- likely 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]) or, less frequently, 66982 (... complex, requiring devices or techniques not generally used in routine cataract surgery or performed on patients in the amblyogenic developmental stage) -- and attach modifier 54. The optometrist will report the same procedure code and append modifier 55.

Remember: You must ensure both provider offices coordinate and enter the number of post-op care days and submit them on both claim forms, Mac says. Often, the ophthalmologist will want to see the patient for at least the initial postoperative day before releasing further care to the optometrist.

Caution: If you're reporting the postoperative care using modifier 55, make sure the surgeon who performed the procedure reported the service using modifier 54, or the carrier will deny your claim because it has already reimbursed the surgeon for providing the full care associated with the code. If this is too difficult to coordinate, your provider can choose to report the appropriate E/M codes instead for the follow-up care.