Ophthalmology and Optometry Coding Alert

Can't wrap your head around the rules for 76519 and 92136? Read on.

In light of advancements in the technology behind A-scans and intraocular lenses, it can be challenging to calculate the IOL power for patients facing cataract surgery. To ensure you're collecting the appropriate reimbursement every time, it's essential that you sidestep the most common myths surrounding 76519 and 92136. Read on to find out how to avoid these commonly-held beliefs.

Myth 1: The bilateral status of 76519 and 92136 is the same whether you report the global code, the technical component, or the professional component

Reality: For both 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) and 92136 (Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation), the technical component has a different bilateral status from the professional component. You can find the bilateral surgery indicators in the fee schedule. Both 76519-TC and 92136-TC are denoted with modifier indicator "2," which means that the technical component of the codes is considered inherently bilateral, just like the global code discussed in myth number one, above.

The work of performing the test on both eyes is included when reporting the CPT^® codes - you should report 76519-TC or 92136-TC only once, whether the ophthalmologist tests one or both eyes.

Here's the difference: The professional components (76519-26 and 92136-26) are denoted with modifier indicator "3," however, which means that the professional component of the codes are inherently unilateral. When you report a global code, without modifiers, you are telling the insurer that you performed the technical component of both eyes and the professional component of one eye for that service. Therefore, you may be leaving money on the table for performance of the professional component on the other eye.

Why?  An ophthalmologist usually performs the technical component of the procedure - the actual measurement of the eye - on both eyes at the same time on the same day. But he may only perform the professional component - the IOL power calculation - on the eye that is going to have surgery.

For example, for an IOL Master and power calculation in both eyes, report the following:

• 92136-TC for the bilateral technical component
• 92136-26-50 for the bilateral professional component. Append modifier 50 (Bilateral procedure) to show that you bilaterally performed this usually unilateral component.

Alternatively, some payers require you to report these services as follows:

• 92136-26-RT and 92136-26-LT

Myth 2: You can always report the A-scan and IOL Master codes together

Answer:  You may be tempted to report both, but the Correct Coding Initiative (CCI) indicates otherwise. CPT^® codes 76519 and 92136 are in a mutually exclusive bundle that cannot be separated, even with a modifier. If you report both codes, Medicare carriers will only reimburse you for 92136.

Example: The ophthalmologist performs the technical portion of an A-scan on the left eye, but dense cataracts prevent him from getting a viable result from the right eye. He performs an IOL Master on the right eye and calculates IOL power for the right eye. You should only report 92136-TC and 92136-26-50.

Do not report the failed 76519 scan and the 92136 scan together. Some payers may have alternative instructions for reporting the A-scan and/or IOL Master when the physician finds it necessary to perform both on the same day. Check with your local payer guidelines for specific guidance.

Myth 3: Report H25 and call it a day

Although H25 (Age-related cataract) is a good start, it's not where you should end your ICD-10 quest. Coding rules dictate that you code as specifically as possible. Since the codes under H25 extend into four characters, you will need a longer code, such as H25.2 (Age-related cataract, morgagnian type), to describe the patient's condition fully.

Tip: Look for helpful notes in your ICD-10 manual. If a code has a checkmark with a number in it next to it (such as "checkmark 4th" or "checkmark 5th"), look above or below it for a more detailed code or specific instructions on adding the additional digits.