Ophthalmology and Optometry Coding Alert

The importance of local policies when it comes to Medicare cant be stressed enough. Without knowing the local policy, you could lose reimbursement. For example, in the August 2000 Ophthalmology Coding Alert, a reader asked how to code epilation using 67820* (correction of trichiasis; epilation, by forceps only). The answer was to bill by the lid, not by the eyelash, and to use -E modifiers (-E1 through -E4, right upper and lower eyelids, and left upper and lower eyelids).

Two readers responded, one in Alabama and one in Texas, whose carriers have different policies. The Alabama reader does get paid per lash using the -Y2 modifier (a state modifier described below) for each lash, and the -E modifiers to indicate which lid. Apparently, Medicare pays Alabama ophthalmologists by the lash. When filing for epilation, use -E codes for the appropriate position, the local Medicare policy states. Use modifiers Y2-Y9 per lash (Y1 does not exist). Each Y code has to be filed on a separate line. Then, list the the following codes (they do not all begin with Y) as needed: -Y2 is the first repeat procedure, -Y3 the second, and so on until -Y9 as the eighth; then -Z2 is the ninth, -Z3 is the 10th, and -99-U2 is for the 11th and balance of lashes.

The Texas reader, on the other hand, is not allowed to bill for each lid and only gets paid for one lash per date of service.

Unfortunately, such wide variances in policy can and do occur in the absence of a Health Care Financing Administration (HCFA) national policy, says Lise Roberts, vice president of Health Care Compliance Strategies, a coding and compliance consulting firm based in Jericho, N.Y. There is no question that the work effort involved in the lash epilation would never support an argument for billing like [the Alabama state policy] at the normal listed Medicare fee schedule based on the RVUs, says Roberts.

If the Alabama carrier has established a lower fee allowance for the epilation code to reflect that they allow multiple lash billing, adds Roberts, then perhaps an argument could be made that the local policy is in keeping with the work effort involved.

Roberts admits that the Texas policy appears to be overly restrictive. Her recommendation in such a case is to contact the state ophthalmological society to find out who the third-party relations liaison is to affirm that youre paid correctly under current policies.