Ophthalmology and Optometry Coding Alert

Watch out for inconsistencies among your carriers

A-scans are some of the most common procedures performed in ophthalmology offices, but coding them can present you with some uncommon problems.
 
According to CPT, A-scans - 76511, 76516 and 76519 - are the shortened names for A-mode scans, "one-dimensional ultrasonic measurement procedures." Ophthalmologists use 76511 (Ophthalmic ultrasound, echography, diagnostic; A-scan only, with amplitude quantification) to diagnose eye-related complications such as eye tumors, hemorrhages, retinal detachment, etc. Physicians use 76516 (Ophthalmic biometry by ultrasound echography, A-scan) to measure the axial length of the eye in preparation for cataract surgery. And 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) is used to determine the intraocular lens calculation prior to cataract surgery only.

Unilateral A-Scans


Not all A-scans are bilateral: Each A-scan code has separate requirements when billed bilaterally. For example, 76511 is considered unilateral, requiring the use of modifiers -LT/-RT/-50 (Left side/Right side/Bilateral procedure) or the units value of "2."
 
But 76516 is considered inherently bilateral, so you shouldn't append modifier -50 to it.
 
Beware: Some carriers consider only the technical component bilateral. Some carriers (including Medicare) have determined the technical component of one of the A-scan codes to be bilateral, and the professional component to be unilateral.
 
Some non-Medicare carriers, on the other hand, want you to bill by line and don't typically divide the professional and technical components, so it is imperative that you determine which carrier you are coding for and what its policy is for billing A-scans.

Master 76519 for Medicare

Medicare's payment policy for 76519 is notoriously confusing. And because both A-scans and cataract surgery constitute a large part of a general ophthalmologist's practice, it's important to know how to bill for 76519.
 
First, an ophthalmologist must perform this procedure before cataract surgery for reimbursement. When you submit claims for ophthalmic biometry - CPT codes 76516 and 76519 - to carriers, you should document the presence of a cataract and your plan for removing it. Make sure there is a written order by the physician in the patient's chart for the A-scan.
 
Clearly convey to the carrier, especially if the carrier is Medicare, which only covers 76519 when it is performed in conjunction with cataract surgery, that the A-scan was performed with the intention of performing cataract surgery.
 
Billing myth: Code 76519 must be billed the date the surgical procedure (typically 66984, Extracapsular cataract removal ...) is performed, and if the surgery doesn't take place, the test isn't billable. In the early 1990s, some carriers did want the billing date for the A-scan to be the same date as the cataract procedure; this is no longer true.
 
If the surgical procedure is not performed, the test is still billable based on medical necessity (diagnosis coding of a cataract).

Bravely Bisect Technical and Professional Components

Second, you must split up the technical and professional components for 76519. Medicare breaks down 76519 into technical and professional components. The technical portion, represented by modifier -TC (Technical component), is the actual measuring.
 
Special equipment takes two measurements - the axial length of the eye and the shape of the cornea - and turns them into a calculation for the power of the intraocular lens implant. The professional component, represented by modifier -26, is for the physician's interpretation and selection of lens type and power for the lens implant.
 
"The problems that I see [coders] create for themselves is that they don't split up the technical and professional components," says Angela Cook, patient accounts manager with West Coast Eye Institute in Lecanto, Fla.
 
Medicare considers the ultrasound itself (the technical component) bilateral, so you should only report it once, even when it is performed on both eyes in a single surgical session.
 
The professional component (or interpretation), on the other hand, is "unilateral" and you should report it for each eye when it is performed bilaterally.
 
In her area, Cook says, Medicare allows only one technical component in a 12-month period. If it has been more than 12 months since the last measurement, you may bill another technical component.
 
The professional component takes place when the ophthalmologist actually selects the power and style of the lens to insert. 

Combat Carrier Discrepancies With Knowledge

Carriers often question medical necessity. Your local carrier determines how often it will reimburse for 76519, both the technical and professional component - and this payment frequency may differ from the above example. Cook is aware of one carrier that will only pay for the service once per lifetime. Keep in mind that when a carrier makes a frequency-of-payment decision, they have based "frequency" on how often they think the service should be medically necessary. If you have a circumstance that differs from the "norm," you can go through the appeals process, prove medically necessity and request payment.
 
Carriers' policies can differ greatly. "The biggest difficulty is knowing just what each individual insurance carrier wants because they all want something different," says Rebecca K. Taylor, CPC, accounts payable manager for Tri-State Centers For Sight Inc. in the greater Cincinnati area. Taylor has gone so far as to set up a meeting with all of her carriers to review how they want A-scans billed in order to clear up inconsistencies among carriers.
  
"We don't have a problem with Medicare Ohio and Medicare Kentucky. We have our set way that we bill it, and it goes through fine," Taylor says. The private carriers are the ones that have been most inconsistent.

Supervision Is Required

Remember: Codes 76511-TC, 76512-TC, 76513-TC (Ophthalmic ultrasound, echography, diagnostic ...), and 76519-TC all require direct physician supervision, which means the ordering physician, or a physician member of the group practice, must be present in the office suite and he must be available to offer guidance and direction if needed during the service.
 
Direct supervision means the ophthalmologist must be in the suite of offices, just not necessarily in the room where the procedure is being rendered.