Ophthalmology and Optometry Coding Alert

To maximize payment for fluorescein angiography (92235) and fundus photography (92250), pay attention to differences between Medicare and commercial payers and understand that various Medicare carriers differ in their policies as well.
Code 92235 for fluorescein angiography (FA) is notorious for being interpreted differently depending on the payer. Fundus photography, another common diagnostic test, is not as problematic. The issue with fundus photography is whether the code represents a bilateral or a unilateral procedure.

Billing Commercial Payers

Most HMOs look at diagnostic procedure codes as involving both eyes, says Heather Freeland, a consultant with Rose and Associates, a reimbursement and coding consulting company specializing in ophthalmology, based in Duncanville, Texas. The reason is that it always works out to be a lower fee. If a code is for both eyes, and its something you usually do in both eyes, the HMO will pay you a single set fee. FA is a bilateral code according to commercial payers, but a unilateral code according to Medicare. When you get to bill twice for it (as you do with Medicare), you get paid more. For commercial payers, if the code specifies unilateral, always use -RT or -LT, says Freeland.

Coding for Medicare

If you want more information about how your local Medicare carrier views these codes, you should check with the Medicare fee schedule database, which most local carriers publish, says Freeland. There is an indicator that applies to bilateral services:

A number 3 indicator means that the code is a per-eye service. If you do both eyes, you should append a -50 modifier (bilateral procedure) or the -RT and -LT modifiers, says Freeland. The physician would get 200 percent of the fee for doing both eyes.

Medicare carriers are not uniform in their processing requirements regarding the -50 modifier and the -RT/-LT modifiers, explains Lise Roberts, vice president of Healthcare Compliance Strategies Inc., a consulting company in Sysosset, N.Y. You should check with your carrier for instructions on the best way to submit services that have the 3 indicator, she says.

A number 2 indicator means that the code is bilateral. You would use no modifiers at all unless you do a one-eye test, in which case Freeland recommends a -52 modifier (reduced services). The physician would get 100 percent of the fee, regardless.

A number 1 is for surgery, which is only per-eye. If done on both eyes, Medicare pays 150 percent of the fee, and you must use either -50 or the -RT and -LT modifiers.

Note: Medicare carriers are not uniform in their processing requirements regarding the -50 modifier and the -RT/-LT modifiers, says Roberts. You should check with your carrier for instructions on the [...]