Ophthalmology and Optometry Coding Alert

Some ophthalmologists perform A-scans (76519) on the same day as cataract surgery (66830-66984). They also want to bill the office visit for the same day. This is basically one-stop shopping, which is convenient for the patient, but getting paid for the office visit may be difficult. Ophthalmologists can bill for all three with modifier -57 (decision for surgery), but your documentation must support this. Its very unusual to have to do a new exam with cataract surgery in one day.

Cataract surgery is usually elective, explains Ramona Cosme, president of Ramco Medical Billing Inc., an ophthalmology coding, reimbursement and compliance consulting firm based in Edison, N.J. To do the office visit, A-scan and surgery on the same day, there would have to be something traumatic to the eye to justify medical necessity. Normally, notes Cosme, a physician performs a consultation, determines there is a cataract, determines what kind of cataract it is, and then schedules surgery. Theres a procedure, and it should be followed, she says. Theres a do it now case, and theres a do it later case. Most cases of cataract surgery are do it later, she says.

When billing the office visit, A-scan, and surgery on the same day, the modifier -57 should be appended to the office visit.

Tip: Make sure you put the -LT or -RT modifier on the cataract surgery code.

Emergency vs. Elective Surgery and Modifier -57

The -57 modifier is to be used when the physicians initial determination that the patient needed major surgery (a procedure with a 90-day global period) was made on that day and the procedure is performed that day or the next day. If the physician had already determined the need for surgery in a previous visit and chooses to see the patient the day before or the day of the surgery, that visit is considered preoperative and is not separately billable. The global surgical package for major surgeries includes preoperative visits that occur the day before or day of surgery. Usually, a decision to do surgery is made at least one week prior to doing the surgery, which enables getting the case scheduled into an operating room (hospital or ambulatory surgical center).

Traumatic cataracts that do not involve other trauma to the eye (e.g., retinal detachment) are not usually emergency cases, explains Lise Roberts, vice president of Health Care Compliance Strategies, a coding, compliance and reimbursement consulting firm based in Jericho, N.Y. Traumatic cataracts typically develop either very rapidly or slowly after the trauma, but even in the rapid development cases there is no immediate threat to permanent loss of the use of vision if the cataract is not taken out.

Retinal detachment repair (67101-67112), however, is a good example of a procedure that is considered an emergency which would warrant an initial decision to do surgery, where the visit occurs either the day of or one day before the procedures, says Roberts. Any of the retinal detachments diagnoses would support the procedure. Another example is a trabeculectomy (66170 or 66172) performed for excessively high intraocular pressure not managed by medication, Roberts says. Such situations can result in permanent loss of vision which is not recoverable if the procedures are not done within a day.

Finally, there are non-emergency cases where it is perfectly appropriate to bill a visit and a procedure using the modifier -57 on the visit code. For example, laser capsulotomies (66821) are often done the same day as the visit in which it was initially determined that the patient needed the procedure. This is done by the physician as a convenience to the patient as an office procedure so the patient doesn't have to return for a separate visit. The diagnosis code should be 366.53.

Itinerant Cataract Surgeons

In addition to emergency based cases, there are some exceptions that involve performing cataract surgery on the same day as the office visit.

There are itinerant cataract surgeons who fly into an area, see patients with cataracts that have been scheduled for examinations (usually by an optometrist or ophthalmologist who doesn't do cataract surgery), perform the surgery, and then fly out, says Roberts. These surgeons do not typically provide any of the post-op care, she says. There are even recorded cases where patients didn't know who to go see after the surgery was done.

Another example is the cataract mill. In this scenario, the surgeon only does the cataract surgery, Roberts explains. Patients are sent to the surgeon, usually by optometrists. The surgeon sees the patient and does the surgery on the same day.

In both of the above scenarios the most typical procedure performed is 66984; any of the fifth digit cataract diagnoses (366.xx) provides medical justification. Whether the visit in addition to the surgery will be paid, even with the -57 modifier, is highly variable from Medicare carrier to Medicare carrier, Roberts warns. Many do not pay on the assumption that there was probably a previous determination that surgery was appropriate.