Ophthalmology and Optometry Coding Alert

Billing bilaterally can save you $130 per procedure

A simple mistake coding the many combinations of strabismus surgery could cost your practice hundreds - unless you know the ropes.Make Modifier -50 Your Secret WeaponScenario: An ophthalmologist removes a 6.5-mm section of the lateral rectus muscle of the patient's left eye and resects the muscle to strengthen it and correct strabismus. He then repeats the procedure on the right eye again removing 6.5 mm of the lateral rectus muscle and then resecting it. Two different codes might look correct - but only one will bring you the reimbursement you deserve.

Because the ophthalmologist performed a resection procedure on two horizontal muscles CPT code 67312 (Strabismus surgery recession or resection procedure; two horizontal muscles) may look correct but don't fall into this trap.

The strabismus surgery codes (67311-67318) describe procedures done in one eye only says Christina Martell CPC billing manager for Pediatric Ophthalmic Consultants in New York City. Even though the surgeon did resect two muscles they were in different eyes so 67312 is not correct Martell says.

Instead you should report 67311 (Strabismus surgery recession or resection procedure; one horizontal muscle) bilaterally Martell says. Most Medicare carriers want you to report the entire session on one line with modifier -50 (Bilateral procedure) and a ""1"" in the units field.

Warning: Reporting 67312 would even hurt your reimbursement in this case. In the Medicare Physician Fee Schedule Database 67311 has a bilateral modifier indicator of ""1."" This means that if you report 67311-50 or report two instances of 67311 on two lines - for example 67311-LT for the left eye and 67311-RT-51 (Multiple procedures) for the right - Medicare will base payment on 150 percent of fee schedule amount for a single code.

Medicare multiplies the facility RVUs for code 67311 (13.39) by the conversion factor of 37.3374 arriving at $499.95. Appending modifier -50 for the bilateral procedure means that Medicare would reimburse you 150 percent of that giving you $749.92.

Reporting 67312 however even though the descriptor mentions ""two horizontal muscles "" will short-change you. With no bilateral pay adjustment the RVUs for 67312 would only bring in $616.08.

Select a Single Code for Single-Eye MusclesTo code strabismus surgery correctly you also need to know when it is not appropriate to report strabismus surgery bilaterally.

If the ophthalmologist recesses both the lateral rectus and medial rectus muscles of the left eye that is not a bilateral procedure. This is a case in which 67312 would be appropriate says Mary Schwall CPC clinical practice specialist at the Yale Eye Center in New Haven Conn.

The same rules apply for the vertical muscles (the superior rectus inferior rectus and inferior oblique muscles).

Use these CPT codes [...]