Ophthalmology and Optometry Coding Alert

Coding for the 90 days following cataract surgery can be tricky. Thats because there are frequently other problems which arise during that period. How can you get paid for handling them, when the fee for the surgery is global?

1. Exam of second eye: Modifier -24 and -LT/-RT.
Lets say the surgery was done on the left eye. But a few weeks later, you need to examine the right eye. How can you get paid for that office visit? The answer is to use modifier -24 and the -LT or -RT modifiers to indicate which eye the service is for, our experts say.

First of all, the -24 modifier is for services provided during the post-op period which are unrelated to the surgery. The -24 modifier is for an unrelated evaluation and management service by the same physician during a postoperative period (CPT 1999).

If the surgery was done on the left eye, and the exam was done during the post-op period on the right eye, you could use 92012-24-RT for the exam, if its an established patient, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., based in Spring Lake, NJ. The reason for the modifier -RT is to tell the payer that there is something unusual, says Brink. The -24 modifier should be used as well, because that tells the payer that the procedure is unrelated to the initial surgery, she says. The -24 modifier is a payment modifier; the -LT and -RT are information modifiers only.

Barbara Cobuzzi, CPC, president of Cash Flow Solutions Inc., a Lakewood, NJ-based medical billing and consulting firm, recommends using both the -24 modifier and the -LT or -RT. You should show the -24 first, and then the -LT or -RT, says Cobuzzi. But you need to show its a different eye, or they wont know.

If you are already using the -24 modifier for this situation and getting the exam denied, definitely use the -LT or -RT, urges Cobuzzi. If that still doesnt work, you may have to do a post-payment appeal. And if that doesnt work, go right to the next level -- a fair hearing, she says. A lot of times they just dont read what youre sending, even on post-payment appeal, she adds. When you go to a fair hearing, and they see the notes and the pictures, they get it -- and they pay. This problem is particularly true for modifier -24, says Cobuzzi.

(Tip: Modifier -24 is only for an E/M services code, explains Brink. If you are using an ophthalmology code for the exam, you cannot use modifier -24. Also, the -LT and -RT are Medicare codes; if the patient is covered by commercial insurance, [...]