Ophthalmology and Optometry Coding Alert

When billing for a procedure performed on both eyes, the coder must know whether the payer interprets the code as unilateral or bilateral. If the code is unilateral, the coder must bill it twice, or the practice will lose revenue unnecessarily. If the code is bilateral, bill it only once or the practice may be found guilty of fraud, especially if that practice has a pattern of billing bilateral codes twice.
 
Most CPT codes are unilateral in the ophthalmology section; however, some are bilateral. Check the Medicare fee schedule database where a bilateral indicator of 0"" means the 150 percent payment adjustment does not apply.
 
The American Academy of Ophthalmology's Web site (www.aao.org) is the best resource for determining the bilateral status of any code " but if you aren't an AAO member. The code covers payment for one eye only. If surgery is performed on both eyes the unilateral code must be billed twice. Most Medicare carriers allow modifier -50 (bilateral procedure) on a single line-item. If the status is bilateral the fee is the same whether the procedure is performed on one eye or both.
 
As Palmetto GBA states in its LMRP on fundus photography 92250 "The reimbursement amount for this service is already based on this procedure being performed as a bilateral procedure. If service is reported with a -50 modifier or with any other indication that it is being billed twice on the same day payment will be based on the reimbursement rate for a single code."
 
Whether a code is unilateral or bilateral is contingent upon national Medicare policy although the filing method for billing a unilateral code for both eyes is up to your local carrier. Some may require two line-items with the modifiers -LT and -RT indicating the left side or the right side while others allow the single line-item billing mentioned above. Check with your carrier if you are unfamiliar with its filing requirements.
 
Most of the procedures that are performed bilaterally are diagnostic or minor surgical procedures. Major surgery on more than one eye at a time is risky says Melissa K. Duchak CPC practice administrator for Bruce E. Kanengiser MD an ophthalmologist in Piscataway N.J. "Most doctors don't do major surgery bilaterally because if something goes wrong the patient could lose vision in both eyes " she says. However blepharoplasty and minor surgery e.g. epilation and punctal plug insertion are often performed on both eyes.
 
Visual Field Testing Determines Bilateral Billing

The most common procedures for bilateral billing when performing visual field testing to check for "blind spots" or loss of peripheral vision include 92081 (visual field examination unilateral or bilateral with interpretation and report; limited examination [e.g. tangent screen Autoplot arc perimeter or single stimulus level automated test such as Octopus 3 or 7 equivalent]) 92082 ( intermediate examination [e.g. at least 2 isopters on Goldmann perimeter or semiquantitative automated suprathreshold screening program Humphrey suprathreshold automatic diagnostic test Octopus program 33]) or 92083 ( extended examination [e.g. Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees or quantitative automated threshold perimetry Octopus program G-1 32 or 42 Humphrey visual field analyzer full threshold programs 30-2 24-2 or 30/60-2]) depending on the intensity of the study.
 
CPT defines visual field examination as "unilateral or bilateral" and Medicare defines it as bilateral only. Both definitions mean the same thing for billing. Whether you perform the procedure on one or both eyes bill the code only once. The fee is the same for a unilateral or a bilateral examination.
 
In reality the physician would perform a visual field test on just one eye when the patient has only one eye or is sighted in only one eye. For example when performing visual field testing on a patient who has had an enucleation bill 92081 92082 or 92083 just as you would for a patient with both eyes.
 
It is not necessary to append modifier -52 (reduced services) to the visual field code when the procedure is done on one eye only as CPT states that the service is "unilateral or bilateral " but some coders do. "It can help when the patient comes to you complaining that he shouldn't have to pay the 20 percent copayment if he only has one eye " Duchak says. "You can explain that you told Medicare that you performed it on one eye only."
 
Some Medicare carriers may require modifiers -LT or -RT when billing a bilateral code for one eye only. These carriers will most likely reduce your fee by 50 percent says Raequell Duran president of Practice Solutions an ophthalmology coding and consulting firm based in Santa Barbara Calif. If the carrier requires modifier -52 it will not reduce your payment. Private payers however may pay less if you append modifier -52.

Medicare Deems Fundus Photography Bilateral

For fundus photography the ophthalmologist uses a retinal camera to photograph the back of the eye e.g. the vitreous retina choroid and optic nerve. Separate pictures are taken for each eye through a large ophthalmoscope. For Medicare patients bill 92250 (fundus photography with interpretation and report) once whether you photograph one or two eyes. Medicare considers this procedure to be bilateral.
 
Commercial payers however may consider fundus photography to be unilateral says Ramona Cosme president of Ramco Billing an ophthalmology coding and billing firm based in Edison N.J. If your commercial payer says 92250 is unilateral list the code twice and append modifier -50 to the second line-item if performed bilaterally for an extra fee.
 
In general fundus photographs are taken bilaterally because the physician needs to compare one eye to the other Cosme says. "When the patient comes back for a follow-up the physician can monitor the progressions of the disease which is usually some type of retinopathy " she says. 
 
If fundus photography is performed on one eye append modifier -52 to 92250 whether the payer is Medicare or commercial Cosme says. Don't use -LT or -RT she says unless instructed to do so by your carrier.
 
A few carriers may require the provider to reduce the fee if it is performed unilaterally says Lise Roberts vice president of Health Care Compliance Strategies a Jericho N.Y.-based company that develops interactive compliance training courses. "You need to be aware of what your carrier requires " she says. "Most however will allow 100 percent of the fee when billing 92250 even with modifier -52 appended."
 
While fundus photography is usually performed bilaterally there are times when only one eye is photographed. For example a patient may have a specific condition in one eye such as a dense mature cataract or a cloudy cornea making it impossible to see the fundus in a photograph Roberts says. When billing Medicare under these circumstances the physician would only order that the eye with clear media be photographed. "If there is a disease process in the back of the eye that you want to document but the media preclude getting it photographed in both eyes you should bill 92250-52 for the eye you are able to photograph " she says.
 
As always when a code such as fundus photography specifies that an "interpretation and report" are included the report for each eye must be in the chart indicating that the physician interpreted the photograph for each eye. If the report is the same for each eye it is acceptable to write it once and indicate that it applies to both eyes e.g. OU.

Correct Billing for Fluorescein Angiography

Fluorescein angiography detects retinal conditions by examining the blood vessels in the retina. It is performed by injecting dye into the arm and viewing the progression of the blood through retinal vessels. A motorized camera automatically takes sequential pictures through an ophthalmoscope to determine if the dye leaks as it recirculates through the retinal vessels.
 
Medicare views fluorescein angiography as a unilateral code. Bill 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report) twice if it is medically necessary to perform the procedure on both eyes. Your method for billing it twice depends on your carrier.
 
For example Cosme says some carriers want a "2" in the units column when billing 92235 instead of two line-items appended with modifier -50. Filing units means a 100 percent reimbursement for each procedure as opposed to 100 percent for the first procedure and 50 percent for the second.
 
If fluorescein angiography is performed on one eye append modifier -LT or -RT. For example if the procedure is performed on the left eye bill 92235-LT. The most common reason for billing 92235 on one eye only is that the patient is monocular. 

Billing Extended Ophthalmoscopy

Extended ophthalmoscopy requires a retinal drawing for each eye and the actual service being performed on each eye. When billing Medicare for an extended ophthalmoscopy on one eye bill 92225 (ophthalmoscopy extended with retinal drawing [e.g. for retinal detachment melanoma] with interpretation and report; initial) or 92226 ( subsequent). Since the code is unilateral append modifier -LT or -RT for informational purposes only because it will not reduce your fee. When billing Medicare for an extended ophthalmoscopy on both eyes ask your carrier exactly how to code the procedure. Some carriers prefer two lines with 92225 on the first line and 92225-50 on the second or 92225-RT on the first and 92225-LT on the second. Some carriers prefer only one line using 92225-50. Some other carriers prefer units such as 92225 with a "2" in the units field. The end result is the same for extended ophthalmoscopy; you will be allowed 200 percent of the fee for one eye.
 
You may wonder why Medicare carriers have so many different ways of filing unilateral codes for bilateral procedures. The answer has to do with their computer processing system capabilities and/or how they have programmed their systems for processing claims. If you follow their instructions and they are allowing for the proper amounts you are doing it correctly for your carrier.

Components Determine Billing for A-Scans

Bilateral performance of A-scans to measure the lens prior to cataract surgery requires a separation of the technical component (the measurement of the patient's natural lens) and the professional component (the physician's selection of the lens that will be inserted).
 
The technical component is considered bilateral by Medicare but and this is where Medicare billing is tricky the professional component is unilateral. The first A-scan code includes the technical component for both eyes and the professional component for one eye while the second A-scan includes only the professional component for the other eye. Do not append modifier -50 to 76519 (ophthalmic biometry by ultrasound echography A-scan; with intraocular lens power calculation) once an A-scan has been performed.
 
For example a patient will have cataract surgery in both eyes but a few weeks apart. If the ophthalmologist decides to operate on the right eye first bill 76519 with modifier -RT appended. The fee will include payment for measuring both eyes and for lens selection (interpretation) of one eye. When the ophthalmologist chooses the lens to be inserted into the left eye for the second cataract surgery bill 76519-26-LT to reflect that the bill is for the professional component only. Another technical compo-nent cannot be billed because Medicare has already paid you for measuring both eyes.
 
If more than a year elapses between the original measurement and the second cataract surgery the ophthalmologist may need to perform a second measurement of the left eye (the length of the eye or shape of the cornea may have changed over that time). Both the technical and the professional components will be performed on the left eye and should be coded as 76519-LT.