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.
 
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