Ophthalmology and Optometry Coding Alert

Code by eye or by eyelid?  CPT rules help--but carriers have the final answer

A patient has multiple chalazions removed from both lower eyelids. The coder submits a claim for 67805-E2 and 67805-E4, but the carrier pays for only one procedure.

The lesson? Eyelid modifiers can sometimes help your claims--but not always. To use the modifiers wisely, you need to know how your carriers view the common eyelid procedures.

CPT provides one modifier for each eyelid: E1 for upper left, E2 for lower left, E3 for upper right, and E4 for lower right. Two common ophthalmological procedures may require the eyelid modifiers: epilation (67820-67825) and chalazion excisions (67800-67805).

Drop Modifiers for Chalazions on Multiple Lids

CPT provides three codes for chalazion excisions in the office: 67800 (Excision of chalazion; single), 67801 (... multiple, same lid) and 67805 (... multiple, different lids). Whether you need an eyelid modifier depends on which of the three codes you are reporting.

Example 1: The ophthalmologist removes one chalazion from the lower right eyelid. Since by definition 67800 can be performed on any eyelid, report 67800. "Appending modifier E4 to CPT code 67800 is not necessary but may provide additional information and clarify anatomical location," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. "Report this modifier if required to do so by your payer."

Example 2: The ophthalmologist removes three chalazions from the lower right lid. Again, by definition 67801 can occur on any eyelid. Report 67801.

As with 67800, appending modifier E4 to 67801 is not necessary but may provide additional information and clarify anatomical location, Mac says.

Example 3: The ophthalmologist excises three chalazions from the right lower lid and one from the left lower lid. Since the definition of 67805 includes "different lids," by definition it cannot occur on just one lid.

"The reimbursement for this procedure is based on multiple eyelids as opposed to a single eyelid," clarifies Part B carrier First Coast Service Options.

"It is inherently understood that multiple lesions are removed from different lids," Mac says. "Medicare has indicated no additional payment for procedure codes 67800-67805 when performed bilaterally on both eyes." For this scenario, report 67805, unmodified.

Append LT and RT for Multiple Lashes

Although there may be some instances in which you append E1-E4 to 67820 (Correction of trichiasis; epilation, by forceps only) or 67825 (... epilation by other than forceps [e.g., by electrosurgery, cryotherapy, laser surgery]), in most cases you won't, experts say. Whether you should append eyelid modifiers to 67820-67825 depends mostly on how the carrier pays for epilation--by eye, by eyelid, by patient or, in rare cases, by lash.

For the epilation codes, CPT 2006 references AMA's July 1998 CPT Assistant, which says that the intent of  67820 is to report the service per procedure, not per eyelash or per eyelid. Many Medicare Part B carriers have used that reference to amend or clarify their rules for 67820, so you can no longer report 67820 once for each eyelid you treat.

Medicare has indicated a bilateral status of "1" for procedure codes 67820-67825. So, when the service is performed bilaterally and reported with modifier 50 (Bilateral procedure) or RT (Right side) and LT (Left side) on separate lines of the claim form, Part B carriers should base payment on 150 percent of the fee schedule amount, says Sunshine Weihert, OCS, coder for Kings Eye Center in Hanford, Calif.

Downside: Most carriers, including Cahaba, HGSA and TrailBlazer, want you to report only one unit of 67820 per date of service, no matter how many eyelashes the ophthalmologist removed from one or both eyes. "This code should only be billed once per session, not per eye, regardless of the number of epilations performed," states TrailBlazer's policy for epilation.

Upside: You may, however, be able to report 67825 once per eye. "Procedure code 67825 can be billed per eye, but not with a quantity more than two," says the TrailBlazer policy.

Example: A patient presents with trichiasis of two lashes of her upper left eyelid, one lash of her lower left eyelid, and one lash of her lower right eyelid. The severity of the irritation to the patient's eyes constitutes medical necessity for removing the lashes. The ophthalmologist performs epilation of all the lashes by electrolysis.

The Part B carrier will reimburse 67825 only once per eye. So even though the ophthalmologist removed one eyelash from each left eyelid, this carrier prevents you from coding 67825-E1 and 67825-E2 for both eyelashes. Code this service once per eye, using 67825-50 (Bilateral procedure), or 67825-LT and 67825-RT.