Ophthalmology and Optometry Coding Alert

Version 8.0 of the Correct Coding Initiative (CCI), effective Jan. 1, 2002, includes several significant new edits for ophthalmologists: Two eyelid reconstruction codes include lesion removal, eye exam and E/M codes include Medicare's new glaucoma screening G codes, and an exam under anesthesia includes gonioscopy. CCI also made some minor edits.
Eyelid Reconstruction
Codes 67961 (excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin) and 67966 ( over one-fourth of lid margin) now have lesion removal codes bundled in. Codes 11640-11646 are bundled into 67961; 11440-11446 and 11640-11646 are now bundled into 67966. The bundling edits have a 1, which means that under certain circumstances different procedures on different lids both are billable with modifier -59 (distinct procedural service) appended. For example, the ophthalmologist removes a small benign lesion from the left upper eyelid (11440) and repairs the right upper eyelid (67961). The ophthalmologist should bill 67961 with modifier -E3 (upper right, eyelid), and 11440 with modifier -E1 (upper left, eyelid) and modifier -59.
Glaucoma Screening
The new Medicare glaucoma screening codes (G0117, glaucoma screening for high-risk patient furnished by an optometrist or ophthalmologist and G0118, ... under the direct supervision of an optometrist or ophthalmologist) are now bundled into eye exam (92002-92014) and E/M codes (99201-99456). CCI made these edits based on "standards of medical/surgical practice." You would be expected to screen for glaucoma in a high-risk patient while performing an eye examination, explains Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. The edits have a 0 for the eye exam codes, and a 1 for the E/M codes, which means that under certain circumstances you can bill Medicare for glaucoma screening plus an E/M code, Roberts says.
 
"For example, if a patient comes in with a simple problem, and the ophthalmologist also performs a glaucoma screening, and the patient does not have glaucoma, the ophthalmologist could code the E/M service and the G code with modifier -59 appended," she says.
 
In another example, a patient comes in for a glaucoma screening, is found to have the condition, and is referred to a subspecialist within the practice for examination on the same day. "The second examination, performed by the subspecialist, would represent a distinct service due to being performed at a different session or patient encounter," says Raequell Duran, president of Practice Solutions, an ophthalmology coding and compliance consultancy based in Santa Barbara, Calif. "The group could then [...]