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 [...]