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 [...]