Ophthalmology and Optometry Coding Alert

Most ultrasound billing involves a global fee, which comprises technical and professional components. If the patient has a cataract in the right eye and none in the left eye, the A-scan would be billed for the right eye with the global fee 76519, which includes both technical and professional components. Without surgery being considered on the other eye, there would not be medical necessity to perform the A-scan on the left eye. (Yes, many ophthalmologists like to have the measurements for comparison, but this does not constitute medical necessity for all carriers, and thus may be difficult to get reimbursed for.)

Why is this so confusing? HCFA decided they would have two payment policies on the two parts of the service, explains Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY. The payment policy for the technical component is that theres one fee schedule allowance which includes measuring both eyes, she says. Then they decided that the professional component -- the interpretation -- is a unilateral fee amount, covering only one eye. In the Medicare fee schedule the code 76519 is listed three times:

1) 76519 (with no modifier)

2) 76519-TC (or -26-RT or -26-LT)

3) 76519-50

(Note: TC stands for technical component, and applies to the procedure itself; 26 is the professional component and applies to the interpretation done by the physician. RT and LT specify the right eye and left eye.)

76519 with no modifier includes the technical component of measuring both eyes, and the professional component for one eye. This has the highest payment of the three versions of 76519.

76519-TC includes only the technical component in measurement of both eyes. This might be used when a physician sends a patient to a hospital for the A-scan. It might also be used, says Roberts, in the office if the physician not only measures both eyes but interprets both on the same day. This claim would have 76519-TC on one line, 76519-26-RT on the next line for interpretation of the right eye, and 76519-26-LT on the next line for interpretation of the left eye. This is the way Roberts recommends coding for this scenario.

(Tip: Be careful about using either the -26 or the -TC modifier for diagnostic services performed in the office. If the physician owns the equipment, then he can only bill for the global service [76519], with no modifiers. If the service is done outside the office or clinic, then the -26 modifier would be used.)

76519-50 is another option. The -50 modifier is used for an identical procedure performed on both eyes during a single session. Depending on the payer, the procedure is either listed twice, or the procedure is listed once with modifier -50 appended to it. Medicare pays twice for the professional component 76519 with modifier -50 appended. However, Kimberly Fennell, CPC, assistant administrator of Baptist Eye Surgeons, a nine-ophthalmologist practice in Knoxville, TN, has a tip here: make sure you double the price. Medicare likes everything on one line, she says. This means that you need to put the -26 modifier and the -50 modifier on one line with the 76519 (i.e. 76519-26-50). Their practices billing department had been billing out for only one eye, assuming that Medicare would double the fee. But that isnt what happens, says Fennell. You should be charging 200 percent of 76519 (to account for the work done on both eyes), and Medicare will discount it, paying you 80 percent of the allowable.

(Tip: Dont you be the one to apply the Medicare discount to your prices: let Medicare do it.)

If a patient has bilateral cataracts and surgery is recommended for both eyes, you would report 76519-26-50 and 76519-TC, says Riva Lee Asbell, a consultant in ophthalmic reimbursement based in Philadelphia, PA. This is because Medicare has decided that each eye may be billed for the professional component, but they will pay for the technical component only once, explains Asbell.

If the patient has bilateral cataracts and the right eye had surgery six months earlier, but now the left eye needs it as well, the following codes should be used, says Asbell: 76519-RT for the first A-scan, and 76519-26-LT for the A-scan done six months later.

What time period must elapse before it is safe to bill the global 76519 again? A year, says Asbell.