Ophthalmology and Optometry Coding Alert

Ophthalmologists who bill 65772 (corneal relaxing incision for correction of surgically induced astigmatism) or 65775 (corneal wedge resection for correction of surgically induced astigmatism) must be able to document that the procedure is being done for surgically induced astigmatism. Medicare will not pay for surgical correction of astigmatism when glasses could correct the problem, unless the astigmatism caused by surgery would be considered significant enough to cause the patient functional problems if corrected by glasses.

Cataract surgery can result in major astigmatism because the shape of the cornea may be significantly altered during an individual patients postoperative healing process, explains Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based fraud awareness and compliance training company. When filing a claim for 65772 or 65775, inform the payer of the patients history of cataract surgery, says Catherine Brink, CPC, CMM, president of Healthcare Resource Management Inc., a coding and compliance consulting firm based in Spring Lake, N.J. Use V45.61 (states following surgery of eye and adnexa; cataract extraction status) for the secondary diagnosis code. For the primary diagnosis code, use the appropriate astigmatism code: 367.20 (astigmatism, unspecified), 367.21 (regular astigmatism) or 367.22 (irregular astigmatism).

If your payers are denying payment, and your operative report appropriately documents the procedure performed as well as documents the diagnosis substantiating the medical necessity for performing the procedure, an appeal should be made for appropriate reimbursement, Brink says.

It is a good idea for surgeons to dictate a short indications section in their operative report that indicates the amount and location of the postcataract surgery astigmatism to be corrected, Roberts says.

Reasons for Denials

Some providers get denials of 65772 or 65775 because too much time has elapsed between the initial cataract surgery and the astigmatism repair. Check with your carrier to find out if there are time limitations between the initial cataract surgery that caused the astigmatism and the operation to repair the astigmatism. Some have no time requirements, while others require the repair to be performed within a year of the initial surgery. If you perform 65772 or 65775 several years after the cataract surgery that caused the problem, you may not be reimbursed for the repair.

In addition, many carriers have a specific requirement for the degree of astigmatism required for the procedure to be considered medically necessary. It is essential to contact your local Medicare carrier for its local medical review policy (LMRP).

Other denials of 65772 or 65775 might be due to a LMRP established by a Medicare carrier that stipulates a minimum amount of surgically induced astigmatism and/or a significant change in the axis of the astigmatism from the precataract surgical state (i.e., 2.5 diopters of astigmatism or more and/or a change of 75 degrees or more in the axis of the astigmatism). If you are receiving denials indicating a lack of medical necessity even though you are using the above-mentioned diagnosis codes, it may be due to such an LMRP. It may be necessary to provide information beyond what an ICD-9 code can communicate when you file these claims. Work with your Medicare carrier to find out how they want you to file these claims so that they are paid correctly the first time.

In addition, some carriers require that the repairs be performed within a certain time following the initial cataract surgery that caused the astigmatism. Other carriers require that the surgically induced astigmatism meet specified criteria such as a significant change in the axis of astigmatism.

Note: Ophthalmologists make every attempt to tie any sutures so that they do not induce astigmatism, Roberts says. Significant astigmatism post-op is usually the result of an individual patients healing process and not due to anything that happened during the surgery.