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 service other than the A-scan and preoperative discussion. But the big change is to remember to use modifier -25 when it is justified. If you do not, even with a good reason to bill for the visit, you wont be paid for it.

If the A-scan is done on the same day that the cataract evaluation is done, there should be no problem billing for both. Bill the level of visit provided, either an E/M code or an eye code, with modifier -25 for the evaluation, and the A-scan code.

Will carriers require that the office visit have a different diagnosis from the A-scan? Not according to CPT or Medicare. The diagnosis code for the A-scan should be the same as that for the visit, Duran says. The reason for the test is the finding from the exam, she says.

Perform the Evaluation on a Different Day

Many physicians prefer to do the A-scan on a different date from the initial cataract evaluation. We dont usually do A-scans on the same day as the evaluation, says Paul C. Abrantes, practice administrator for South Coast Eye Care in North Dartmouth, Mass. Medically and legally, its better to have the patient think about the surgery first. You tell them they need cataract surgery, and then do the A-scan the next week. That way, they dont feel as if theyre being rushed into it. They can think about it for a week. Abrantes policy is for the A-scan to be done two weeks after the evaluation.

David D. Richardson, MD, an ophthalmologist who practices in San Gabriel, Calif., agrees. I dont like to schedule surgery with a patient Ive just met, he says. I like to have them come back for the A-scan, and then I can talk to them more and develop a rapport. At the initial evaluation, Richardson lets the patient know about the cataracts and the treatment he recommends, and then he lets the patient think about it for a bit.

Richardson bills a doctor visit with the A-scan because he does the preoperative exam on the same day as the A-scan. I want to know myself that their general health is good, he says. He bills a 99212 or, if he does a full physical, 99213 along with the A-scan. Now, he must append modifier -25 to those E/M services codes. Richardson explains that he does the pre-op himself because the hospital doesnt usually give him pre-op clearance until the day before, or sometimes the day of, surgery. I dont like to be surprised, he says.

Most of Richardsons cataract patients have other problems in addition to cataracts, so he does not feel it is difficult to justify the office visit. If I need to check a patients glaucoma (365.xx) or ocular surface disease, at the same time that I do an A-scan, I can bill for both, he says. The key to getting paid for the office visit is to add modifier -25.

In addition to the clinical benefits, its more convenient to have regularly scheduled times for A-scans, such as Tuesday and Thursday mornings. We set aside time for A-scans and can do them one after another. But convenience alone does not justify getting paid for 99211 at the same time as the A-scan, as Abrantes knows. We dont bill a 99211 with the A-scans any more, he says. Its not appropriate.

Tip: Use modifier -25 on the E/M for private payers as well as Medicare, since many private payers use the CCI edits.