Ophthalmology and Optometry Coding Alert

Improperly coding IOL Masters or A-scans can cost your practice $30 per patient Calculating intraocular lens power for patients facing cataract surgery has gotten more precise as A-scan and IOL Master technology has advanced. But to make sure your practice is getting fairly reimbursed each time, you need to understand the bilateral rules for 76519 and 92136.
 
Could one of these myths be damaging your claims? Include Bilateral and Unilateral Components in Global Code Myth: If the ophthalmologist calculates IOL power in both eyes, you should report  76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) or 92136 (Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) twice (e.g., 76519-RT and 76519-LT, or 76519-50). Reality: You should not report 76519 or 92136 bilaterally, even if the ophthalmologist calculated the IOL power of both eyes. To understand why, it's helpful to know how Medicare's Physician Fee Schedule values the procedures.
 
As it does with many other diagnostic tests, CMS divides the A-scan (76519) and the IOL Master (92136) into two components, says Amanda Kunze, CPC, OCS, coder and reimbursement specialist for the Eye and Ear Clinic of Wenatchee in Washington state. The technical component (the actual performing of the test) is marked with modifier TC, and the professional component (viewing and interpreting the results) is marked with modifier 26, Kunze says.
 
For most procedures, the technical and professional components have the same bilateral status -- for example, 92250-TC and 92250-26 (Fundus photography with interpretation and report) are both considered inherently bilateral, marked with modifier indicator "2" on the fee schedule. The reimbursement for all components of 92250 is based on both eyes being tested.
 
Exception: For both 76519 and 92136, the technical component has a different bilateral status from the professional component, Kunze says. Both 76519-TC and 92136-TC are marked with modifier indicator "2," which means that the codes are considered inherently bilateral. The work for performing the procedure on both eyes is included in the single CPT codes -- you should report 76519-TC or 92136-TC only once, whether the ophthalmologist tests one or both eyes. Code Components Separately if Both Eyes Tested The professional components (76519-26 and 92136-26) are marked with modifier indicator "3," however, which means that the codes are inherently unilateral. When you report a global code, without modifiers, you are telling the insurer that you performed both the technical and professional components of that service.
 
Why? Ophthalmologists usually perform the technical component of the procedure -- the actual measurement of the eye -- on both eyes at the same day. But he may only perform the professional component -- the IOL power calculation -- on the eye that is going to have surgery. For example, [...]