Ophthalmology and Optometry Coding Alert

LASIK (laser-assisted in situ keratomileusis) is a high-paying refractive procedure and is not covered by most insurance plans, including Medicare. In some instances, LASIK is considered a self-pay procedure, or it may be covered by insurance. There is no CPT code specifically for LASIK.
 
To bill the procedure correctly, according to CPT convention, use 66999 (unlisted procedure, anterior segment of eye) unless the payer gives instructions in writing to use a different code. You may code 66999 for any insurance-covered LASIK procedure where instructions for coding have not yet been issued by the payer and if the patient is paying for the entire procedure out-of-pocket, but many plans that cover LASIK require 65760 (keratomileusis).
 
According to CPT , this code is technically incorrect, but the payer has the right to make exceptions for which codes it will reimburse. If" in fact there is documentation from the payer saying to use that code such as a payer newsletter or letter it's OK to use it " says Lise Roberts vice president of Health Care Compliance Strategies a Jericho N.Y.-based company that develops interactive compliance training courses. If the payer audits you and finds out you have been billing 65760 for LASIK it  cannot accuse you of billing fraudulently. "They will have no recourse because you have the newsletter or letter from them on file telling you to bill LASIK with 65760 "  Roberts says.

LASIK versus Keratomileusis

 
Although "keratomileusis" is a component of the acronym LASIK many coders believe 65760 may be used when coding the LASIK procedure but it is not appropriate. The descriptor for 65760 does not include what is done for LASIK says Michael X. Repka MD American Academy of Ophthalmologists' advisor to the AMA CPT advisory committee. If a payer requests that you use the code that is what you should do he says. In fact keratomileusis is no longer performed making 65760 an obsolete code. LASIK is now considered the standard practice.
 
LASIK is a less complicated procedure than keratomileusis. With LASIK the ophthalmologist uses a knife to cut a flap in the cornea. The surgeon lifts the flap and then uses an excimer laser which is controlled by a computer to flatten the underlying cornea. The surgeon then replaces the flap and the cornea heals without stitches. Performed under local anesthesia LASIK is popular because of rapid healing and quick return of vision. As with all surgeries there is always risk.
 
A true keratomileusis procedure on the other hand involves shaving off a section of the cornea with a knife reducing it with laser shots and then replacing the section. This procedure requires much more time and skill and also causes more discomfort than LASIK.

Reimbursement for LASIK Procedure

 
No special LASIK code will be developed. If it were it would not benefit any ophthalmologists performing the procedure. Medicare may assign RVUs to a new code that is much lower than those assigned to 65760 and commercial payers who use 65760 rely on the Medicare fee schedule. Ophthalmologists who bill based on that code are reimbursed well. Even though they are billing an incorrect code according to CPT it is considered ethical because payers have requested this code be used.
 
As long as Medicare does not cover refractive surgery there will be no codes and therefore no RVUs for that procedure. Although the unlisted-procedure code is technically correct for LASIK commercial payers do not like them. Unlisted-procedure codes require a review by a claims examiner. CPT codes can be set up in the computer system to be covered or not and a coverage list of diagnosis codes can be assigned to CPT codes. With unlisted-procedure codes (e.g. 999) insurance carriers are not able to create an automated process. As a result unlisted-procedure codes cost the payers more to process and take more time.

Employer Groups Determine Coverage

 
"It's not the payer who determines whether these procedures are covered but the employer " says Laurie Hegtvedt office manager for North Iowa Eye Clinic in Mason City. "But it's the payer who tells you how to code for it." Recently Blue Cross told Hegtvedt's office to bill for LASIK using 65760. "It's mostly union plans " she notes.
 
In fact plans that cover LASIK are generally employers that believe it is an occupational benefit not to wear glasses. With each procedure costing about $3000, it is a big expense to add as a benefit. Union plans (for workers such as electricians steelworkers policemen and firemen) tend to have plans that cover refractive surgery.
 
"Bausch and Lomb provides coverage for LASIK procedures to its employees " says Melissa Duchak CPC an ophthalmology coding consultant based in Piscataway N.J. "So does Merck." The employers she says want the technicians in these companies to be able to work without glasses.
 
If one company requires you to bill 65760 for LASIK it does not mean that all companies require you to bill the  same code. Some companies that cover this procedure may want you to code correctly with the unlisted-procedure code. And do not assume that because one company has a certain health insurance plan that covers LASIK that all plans offered by that company cover the procedure. For example U.S. Healthcare does not as a rule pay for LASIK but covers it for Merck employees.
 
Do not expect Medicare to ever cover LASIK for correction of refractive error but Medicare carriers do pay for correction of surgically induced astigmatism and some have added LASIK as a method for the correction to their LMRPs says Raequell Duran president of Practice Solutions an ophthalmology coding and compliance consultancy based in Santa Barbara Calif. Medicare pays for 65760 a bona fide keratomileusis procedure (not LASIK) in some cases of keratoconus.

Track Your Procedures Carefully

 
Physicians must track their procedures even if there is no code for them. If the patients pay for the procedures as in the case of LASIK practices may use 66999 65760 or a dummy code (a fictitious code made up by the practice) to distinguish between those patients who have coverage and those who do not.
 
The unlisted-procedure codes are not specific to any certain type of procedure   Roberts says. The best way to use unlisted-procedure codes is to record them in the code file with a description of LASIK attached. When unlisted-procedure codes are recorded in this way it is obvious that the procedure was LASIK.
 
Dummy codes can be used as well as they provide an opportunity to track the procedures. Some computer systems allow up to seven digits for codes. As a result you could use 65760 or 66999 and add your own dummy modifier that signifies LASIK.
 
Some patients have insurance coverage for LASIK but most do not. It is important to have a flag in your computer program and within the chart that prevents you from seeking reimbursement from the insurance company especially if the policy does not cover LASIK and the patient is responsible for payment of the surgery.
 
Some practices use dummy codes in certain instances and 65760 or an unlisted-procedure code in others. You can also use a dummy modifier on both codes. You may then use a different dummy modifier to signify non-insurance-covered or patient-pay on both codes. The tracking of insurance or non-insurance coverage would then take place based on the modifier and code combination.

Bill Two Units for Two Eyes

 
Standard surgical practice is to perform LASIK on both eyes at the same time says John Pinto president of J. Pinto and Associates a San Diego-based ophthalmology practice management consultancy. Because you are not billing Medicare you may bill the same amount per eye.
 
"We bill by the eye the same amount per eye " Hegtvedt says. If only one eye is done bill 65760 with the -LT or -RT modifier. If both eyes are done at the same time bill two units of 65760.
 
While Medicare and other payers who cover LASIK will not pay 200 percent of a procedure with modifier -50 (bilateral procedure) appended there is no restriction on billing self-pay patients. Some patients prefer to have one eye done at a time with a two-week interval in between surgeries Duchak says. "That's because as with cataract surgery they are afraid that something might go wrong." Other patients prefer only one surgery. In any event you do not have to worry about Medicare's global rules. You can do the second procedure two weeks after the first one without appending any modifiers or getting any reduction in fee.

Reducing the Fee

 
The majority of plans that cover LASIK allow 80 percent of what the Medicare fee schedule allows. The average per-eye LASIK fee has dropped considerably with recent competition Pinto says. Many surgeons have decided to focus on LASIK rather than limiting it to 10 or 20 percent of their practice. This has driven the price down from an average of $2000 per eye to an average of $1100 per eye he says. Marketing costs which can account for about 20 to 30 percent of the procedure and the cost of updating machinery (lasers cost $500 000) contribute to a lower profit margin on LASIKs. The average per-procedure profit used to be $1 000 for LASIK Pinto says; it is now below $500.

What About Enhancements?

 
Some LASIK packages include an "enhancement "  Duran says and some include postoperative care for up to one year. Marketers can use this in positioning their physicians to sell LASIK. For example a patient may have 20/20 vision after the procedure but a month later the cornea changes and the patient's vision has slipped to 20/40. The ophthalmologist can do an enhancement with the laser and fix the problem. Some physicians will bill extra for the enhancement; others build the cost of the enhancement into the fee.

The Purist Viewpoint

 
Some coders do not agree with billing 65760 for LASIK in any instance. "You have to use proper coding regardless of who is paying " says Catherine Brink CMM CPC president of Healthcare Resource Management Inc. in Spring Lake N.J. "You can't just make up your own code. If the unlisted-procedure code is the right one use that one even if the patient is self-pay."
 
For internal and auditing purposes you should always use the same code for the procedure Brink says. This way not only do you have a record of when the procedure was performed but you can lobby the AMA for a code if needed.
 
"I wouldn't bill LASIK with anything but the unlisted-procedure code " says Mary Jo Scacchi business administrator for Eye Consultants of Northern Virginia a three-provider practice in Springfield. "I would not agree to 65760 that is an incorrect code." Her physicians do mainly LASIK and cataract surgery.