Ophthalmology and Optometry Coding Alert

Ophthalmology coders often dont know whether to code epilation (the removal of an ingrown eyelash) per lid or per eye. CPT says to CPT 67820 (correction of trichiasis; epilation, by forceps only) and 67825 (correction of trichiasis; epilation by other than forceps [e.g., by electrosurgery, cryotherapy, laser surgery) per eye (maximum of two payments). But most Medicare carriers say to code per lid (maximum of four payments), and in the absence of any national Medicare policy, HCFA agrees with CPT (CPT Assistant, July 1998). To maximize reimbursement when performing epilation in more than one lid, ophthalmologists should use eyelid modifiers when billing Medicare.

Epilation Coding for Private Payers

For example, if an ophthalmologist epilates two lashes in a patients lower left lid, three in the upper left lid, and six in the upper right lid by forceps, code 67820-LT on the first line, and 67820-51-RT on the second line. It doesnt matter which gets modifier -51 (multiple procedures) because they are the same. Usually, you list the highest-paying procedure on the first line. You get paid the full fee for the first, and half of the fee for the second procedure. Many HMOs and PPOs consider this the correct way to handle lash epilation coding and payment.

Epilation Coding for Most Medicare Carriers

A Medicare carrier that pays by the eyelid, such as Administar Federal (Indiana and Kentucky) or First Coast (Florida), would have you code the same scenario as follows: 67820-E2, 67820-E1-51 and 67820-E3-51. (Modifier -E1 is for the upper left eyelid, -E2 is for the lower left eyelid, -E3 is for the upper right eyelid, and -E4 is for the lower right eyelid.) You would be allowed the full fee for the first line billed, and 50 percent of the fee schedule for the second and third lines. This is substantially more than you would get for this scenario by coding under the CPT guidelines.

Bill According to Payer Policy

There is a range of payment policies on epilation from Medicare carriers, and most of the patients who need this procedure are Medicare patients, says Michael X. Repka, MD, the American Academy of Ophthalmologys representative to the AMA CPT Advisory Committee. If its not for a Medicare patient, the procedure is for the eye, and not the lid. If its for Medicare, you have to check the policy and bill accordingly, says Repka, who practices at the Wilmer Eye Institute at Johns Hopkins in Baltimore.

Some coders file the epilation with the eyelid modifiers, even if billing to a commercial payer. Generally, this is only done on a Medicare patient, says Roxanne Oyler, CPC, business supervisor for Kentucky Eye Care in Louisville, Ky. But she would not change her coding for the payer. Oyler codes epilation per eyelid for both Medicare and commercial payers and is reimbursed for it.

Ophthalmology coders who bill with the eyelid modifiers to a commercial payer may, however, face denials because the lid modifiers (E1-E4) are HCPCS codes and are not listed in CPT. Payers other than Medicare may not recognize HCPCS codes, says Raequell Duran, president of Practice Solutions, an ophthalmology coding and compliance consultancy based in Santa Barbara, Calif. For example, if the payers policy is to pay per eye, and lashes were epilated on all four lids, the payer would reimburse for one eye at its full normal fee schedule and the other at 50 percent of its fee schedule, and deny the other two line items.

If your carrier pays by the lid, or even by the lash, thats how you should continue to bill and be paid. If not, contact your medical society and ask it to take up the matter with your Medicare carrier. They can even contact the medical society in another state that succeeded in getting the per-lid coverage, and benefit from that paperwork.