Ophthalmology and Optometry Coding Alert

A-scans (76516-76519) are now bundled into evaluation and management (E/M) services codes and eye exam codes. But ophthalmologists can get paid for the office visits by using modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), if there is a separate reason for the office visit. If ophthalmologists dont use the modifier, they will be paid for the A-scan only. But if they use modifier -25 when it is not justified, they will be committing fraud.

The Correct Coding Initiative (CCI) version 6.3 requires physicians to use modifier -25 on E/M codes or the eye exam codes when billing them with various diagnostic procedures, such as A-scan. The two main points ophthalmologists need to keep in mind about the A-scan edits are (1) use modifier -25 on the office visit when the A-scan is provided on the same day, and (2) do not use modifier -25 unless a significant, separately identifiable service is provided.

The main point of these edits is to prevent providers from automatically tacking 99211 (office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician) onto every scheduled diagnostic service that they perform. Not only would that be representative of what HCFA and the Office of the Inspector General (OIG) refer to as a standing order, but it also represents billing for a not medically necessary service both of which are serious types of billing fraud, says Raequell Duran, president of Practice Solutions, an ophthalmology coding and compliance consulting company based in Santa Barbara, Calif.

If the ophthalmologist sees a patient for a cataract evaluation and schedules an A-scan for some time in the future, you will not be able to bill an office visit with the A-scan unless an examination is performed by the physician in addition to the A-scan service on that day.

Many ophthalmologists were having their technicians perform A-scans, and then billing 99211 in addition to the A-scan for a preoperative discussion with the patient, without any other problem being addressed by the physician. This practice is probably what was behind the rationale that resulted in the testing services being bundled, Duran says. It is no longer possible. The ophthalmologist must provide a separately identifiable service to be reimbursed for the office visit and the A-scan.

The fact that you cant bill for an office visit with every A-scan isnt a big change. Even before the bundling edit, providers should not have billed 99211 with A-scans if they provided no medical [...]