Ophthalmology and Optometry Coding Alert

Ophthalmologists should bill for both eyes together when performing the technical component of an A-scan for reimbursement from Medicare. But for reimbursement from commercial payers, code each eye separately.

Correctly Code for Medicare Reimbursement

Medicares payment policy for 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) is one of the most confusing policies in existence. This procedure must be done before cataract surgery, and both A-scans and cataract surgery constitute a large part of a general ophthalmologists practice, so it is important for coders to know how to bill for 76519.

Medicare breaks down 76519 into technical and professional components. The technical portion is the actual measuring, which is done with equipment that takes two measurementsthe axial length of the eye and the shape of the corneaand turns them into a calculation for the power of the intraocular lens implant.

Note: Not all offices can do both with one piece of equipment. In fact many offices have to do the keratometry separately and feed the readings into the A-scan equipment for use in the IOL calculation.

Medicare will only allow one technical component in a 12-month period. If it has been more than 12 months since the last measurement was performed, then another technical component may be billed. The professional component takes place when the ophthalmologist actually selects the power and style of the lens to insert. Both eyes need to be synchronized to work together, so that perfect vision may not be the best power for an IOL. Medicare allows the professional component to be billed once for each cataract surgery, even if the professional component for the other eye (and technical component for both eyes) was done recently. Here are some Medicare billing scenarios, courtesy of Lise Roberts, vice president of Health Care Strategies of Syosset, N.Y.

Scenario 1: The patient has cataracts in both eyes that impair vision by approximately the same amount. The physician does the dominant eye (right eye in this example) first and plans to do the other eye soon after the first eye is healed. The A-scan and keratometry are performed to measure both eyes and the physician selects the power and style to implant into the dominant eye. The first claim will reflect 76519-RT. The Medicare Physicians Fee Schedule (MPFS) for 76519 includes payment for measuring both eyes and interpreting one eye. Later, when the physician selects the power and style of the IOL for the other eye the second claim will reflect 76519-26-LT. The MPFS for 76519-26 includes payment for the interpretation only, resulting in the selection of the power and style of the IOL.

Scenario 2: The patient has cataracts in both eyes except the right eye needs cataract surgery and the left doesnt yet. The A-scan and keratometry are done on both eyes and the selection of the power and style of the IOL for the eye to be operated is performed. The claim will reflect 76519-RT. A year-and-a-half later the left eye needs surgery also. Because the standard of practice is to measure the eyes again if it has been more than one year since they were measured, Medicare allows payment for another technical component. The claim will reflect 76519-LT.

Commercial Carriers Pay Better for A-scans

Commercial payers, however, do not make it so difficult. The coding for A-scans for commercial payers is fairly straightforward, and, as a bonus, they pay much better for A-scans than Medicare does. The down side is that cataract surgery is far more likely to occur in older patients than in younger patients.

However, coders need to know how to bill for A-scans regardless of who the payer is. Many practices assume that its best to bill every procedure the same way, regardless of payer. This kind of philosophy rarely has a good outcome since payer payment policies vary widely. You need to determine how payers want you to file a claim, and then you need to file it that way.

Heres how the coding differs: Medicare pays you once to measure both eyes and once to interpret each eye, explains Donna McCune, CCS-P, associate consultant with Corcoran Consulting Group, an ophthalmological coding and reimbursement consultant based in San Bernardino, Calif. The first time you do the A-scan you bill Medicare 76519, says McCune. That means that you measured both eyes and interpreted one. Then, if you need to perform surgery on the other eye three months later, for example, you dont need to do another scan, but just another interpretation for the other eye. So for the second eye, you bill Medicare 76519-26, adding -LT or -RT, says McCune (see billing scenario #1). That means you will only get paid for the professional component for the second eyea much lower fee.

Commercial payers, however, just ask for the eye modifier. In other words, the first time you do an A-scan and its on the left eye, you would bill 76519-LT. Then, when you need to do the right eye three months later, you bill 76519-RT. Theoretically, the commercial payer is going to pay better because they will be paying for a technical component and professional component each time. This is because they are only paying for the measurement of one eye at a time and not both eyes as Medicare does.

Lets say the MPFS for 76519, measuring (technical) and interpretation (professional) components, is $100. Medicare would allow you $100 for the first eye and a vastly reduced fee for the professional component when the second eye is billed, explains McCune. But lets say the commercial carrier is an 80-20 plan. They would pay you $80 for 76519 on the first eye and $80 for 76519 on the second eye. Thats a total of $160, with the patient paying the remaining $40. Of course, plans have different fee schedules in the first place. However, McCune notes that in virtually all cases, commercial carriers do pay better.

Coding for Immediate Cataract Surgery

In addition to 76519 with no modifier, and 76519-26, there is one other permutation of A-scan billing for Medicare. It is 76519-TC, which includes payment for the technical component only for both eyes. This comes into play when a patient has cataracts in both eyes which are so bad that the ophthalmologist decides to do surgery on both eyes immediately. The ophthalmologist performs the technical component and the professional component for both eyes at the same time. This would have to be coded on more than one line. The first line would be coded 76519-TC. Payment would be automatically bilateral. The second line would be 76519-26-50, with -26 signifying the professional component, which is defined as unilateral, and -50 indicating that both eyes were done, doubling the reimbursement for 76519-26.

So the form would look like this:
Line 1: 76519-TC
Line 2: 76519-26-50

Some Medicare carriers dont accept the -50 modifier, however. Instead, they want you to use the eye modifiers. For these carriers, there would have to be three lines on the claim form, in the case of the patient who needed both eyes done immediately. The first line would be 76519-TC, the second line would be 76519-26-RT, and the third line would be 76519-26-LT. The form would look like this:

Line 1: 76519-TC
Line 2: 76519-26-RT
Line 3: 76519-26-LT

If this seems like a very confusing topic, dont worryit is and you are not alone in your confusion. Although this Medicare policy has been in place since May of 1993, I still spend a lot of time explaining it in seminars around the country, says Roberts. It is the only policy of its kind in the whole Medicare program. No other code in CPT has two separate payment policies for the technical and professional components of a service.