Ophthalmology and Optometry Coding Alert

CMS decision allows you to append modifier -50 to 46 additional procedures

If you've gotten used to reporting certain eyelid excisions without appending modifier -50 (Bilateral procedure), hold onto your hat. Medicare has announced a change in its thinking for 46 eye surgery CPT codes, allowing you to bill them bilaterally for a 150 percent fee adjustment.

The first update to the 2005 Medicare Physician Fee Schedule, announced in CMS Transmittal 475 on Feb. 11, changes the bilateral indicator for these procedures from "0" to "1." Bilateral indicator "0" means that Medicare carriers will not adjust the fee for that CPT code if you report it bilaterally (using modifier -50 or the -LT and -RT modifiers) - they will only pay for a single code.

Bilateral indicator "1," however, means that the 150 percent fee adjustment for bilateral procedures does apply. If you report a CPT code marked with "1" with a bilateral modifier, Medicare will base the payment on 150 percent of the fee for a single code or the full amount you charge for two codes - whichever happens to be lower.

Why? You can thank the American Academy of Ophthalmology (AAO) for the change, says DeChane Dorsey, the Academy's director of health policy. "The changes to the ophthalmology codes were the result of an academy letter to CMS in January 2005, asking that the bilateral surgical indicator be changed," Dorsey says. "These changes are positive for ophthalmology because now those procedures can in fact be billed at 150 percent if done on both eyes. Previously, you could only obtain 100 percent of the fee if you did both eyes on the same day."

Example: Your ophthalmologist performs 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) on both eyes. You report 67961-LT on one line of the billing form and 67961-RT on the second line, or 67961-50.

Prior to this change, Medicare would have paid for only one of the codes (14.69 RVUs, unadjusted for location, when performed outside a facility, translating to $556 after multiplying by the 37.8975 conversion factor). After this change, however, Medicare should allow 150 percent of the fee for 67961 - about $835 - for a bilateral procedure.

The change will be implemented on April 4. The effective date for the change is Jan. 1, 2005, meaning that it affects services rendered any time this year. Practices should send in claims for services already billed and paid prior to this update for services rendered on or after Jan. 1, 2005.

Note: To read the full change request, with a complete list of the affected codes, visit www.cms.hhs.gov/manuals/pm_trans/R475CP.pdf.