Ophthalmology and Optometry Coding Alert

If you file Medicare claims electronically, as most ophthalmologists do, you know that you cant get more than two modifiers in the modifier field. This presents a problem for ophthalmologists who must use more than two modifiers.

This comes up frequently in the following situation: An ophthalmologist co-manages cataract surgery with an optometrist. The ophthalmologist performs the surgery, and the optometrist follows the patient through the post-operative period. The global fee for postoperative care must therefore be prorated, with the ophthalmologist only getting paid up until the optometrist takes over. But how can you convey the many modifiers that apply when you are filing the claim?

Successfully Listing Modifiers

The answer may vary depending upon the Medicare carrier with whom you file claims. Laurie Hegtvedt, insurance supervisor for North Iowa Eye Clinic in Mason City, Iowa, says the answer in her area is to file the claims on paper. They need to give you room for all the modifiers on the paper claims as it is, says Hegtvedt. Electronically, its impossible.

But its not enough to just use paper. You must also list the modifiers in the correct order, says Hegtvedt. There are pricing modifiers and processing modifiers, she says. You should always put the pricing modifiers before the processing modifiers. In the example of the co-managed cataract surgery, Hegtvedt often uses the following order to file the claim: 66984 for the implant, followed by modifier -99 (multiple modifiers) to alert Medicare that more is to come, modifier -54 (surgical care only), and modifier -51 (multiple procedures) when applicable. Hegtvedts practice may perform a trabeculectomy at the same time as a cataract procedure.

In the cases in which Hegtvedts practice does multiple procedures, such as the cataract and the trabeculectomy, both are co-managed; the optometrist follows the patient for both. We claim up to the day before the optometrist sees the patient, she explains.

Hegtvedt notes that she must also bill the other side of the equation. Sometimes her practice does the follow-up after a patient has been to the Mayo Clinic for surgery. With these claims, she also must file on paper. And even though the surgery is not being done by her practice, she always indicates the surgery date in block 24 of the claim form. This makes it easier when Medicare is tracking both providers.

Some Medicare carriers have set up their electronic claims processing systems to recognize the -99 modifier, explains Lise Roberts, vice president of Health Care Compliance Strategies, a coding and reimbursement consulting firm based in Jericho, N.Y. These processing systems will require a claims processor to go to the note or comment field to find out the additional modifiers that apply before determining payment. When you file an electronic claim in this way, says Roberts, list the modifiers in the same order recommended above for the paper claims, but after the -99 place the -54 and if applicable the -51 modifier in the note or comment field like this: 99, 54, 51.

Tip: You may not have a note or comment field in your computer system. Contact your vendor to request this feature.