Ophthalmology and Optometry Coding Alert

If you're treating Medicare and private payers the same, you're losing payments

If you're including your ophthalmologist's care for postsurgical complications in the global surgical package of the primary procedure every time, you're missing out on legitimate revenue.

To determine if you deserve additional reimbursement, ask yourself two questions:

Question 1: Did the Doctor Go Back to the OR?

For both Medicare and private payers, you'll have to append a modifier to the appropriate CPT code to describe the ophthalmologist's treatment of the postsurgical complication. If the ophthalmologist is returning to the operating room during the global surgical period of a previous procedure, the correct modifier is 78 (Return to the operating room for a related procedure during the postoperative period), says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues in Fountain Valley, Calif.

CMS and CPT agree: You should use modifier 78 to indicate a return to the operating room for both private and Medicare payers, says Debra Duran, CPC, coder for Eye Associates of New Mexico in Albuquerque. CMS guidelines specifically note that modifier 78 "indicate[s] that the service necessary to treat the complication required a return to the operating room during the postoperative period."

Example: Five days ago, an ophthalmologist performed trabeculectomy (66170, Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery) on a patient, who now presents with hyphema (364.41, Vascular disorders of iris and ciliary body; hyphema). Because the hyphema does not resolve on its own, the ophthalmologist washes out the anterior chamber in the OR. Report 65815 (Paracentesis of anterior chamber of eye [separate procedure]; with removal of blood, with or without irrigation and/or air injection) with modifier 78 appended.

Question 2: Who's the Payer?

Medicare treats postoperative complications differently than insurers who follow CPT guidelines. Although both CMS (Medicare) and CPT (AMA) guidelines indicate that the global surgical package includes "typical" postsurgical care, the two sources differ on what qualifies as typical--which means you must differentiate your claims depending on the payer you are billing.

Medicare requires that a complication be significant enough to warrant a return to the operating room before you may report a separate procedure. CMS "Correct Coding" guidelines specifically state, "When the services described by CPT codes as complications of a primary procedure require a return to the operating room" you may report a separate procedure.

But CPT guidelines are less strict. You may report some postoperative services during the global period that the ophthalmologist provides in the office. This means, for instance, that you could collect an additional $80 from private payers for a level-four established patient visit (99214) to deal with a patient's postoperative infection.

Bottom line: If treatment of a postoperative infection (for instance) requires that the ophthalmologist return the patient to the operating room, you may report the procedure for either Medicare or private payers. If the ophthalmologist can treat the infection in his office, however, you may only file a claim for those payers that follow CPT guidelines by using modifier 24 on the E/M service.

Turn to 24 for Unrelated E/M Services

To gain reimbursement from private payers for unrelated, in-office postoperative evaluations during the global period, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M service code, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.

Remember: You can't charge separately for in-office post-op care for Medicare payers.