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 best way to submit services that have the 1 indicator.

Coding for Fluorescein Angiography

Medicare interprets 92235 as a unilateral procedure, so you would bill the code twice if you do it twice. FA is often done bilaterally, so most of the time you will be billing 92235 for each eye if the payer is Medicare. Make sure you double your fee, because Medicare allows the full Medicare fee schedule for each eye.

Even for Medicare, some experts recommend using the eye modifiers (-RT and -LT), especially if you perform 92235 bilaterally, just so the Medicare carrier clearly understands that you have not done the procedure twice in the same eye. If you do this as a two-line entry, put your full fee after each. If you submit this as a single-line entry using the -50 modifier, make sure you find out from your Medicare carrier how many units to put in the unit field, says Roberts. Some want 1 in the unit field, and others want 2.

For private payers, you should always check to find out how they want you to file 92235. Most HMOs want a two-line entry, with -RT and -LT.

Coding for Fundus Photography

Fundus photography (92250) is interpreted by Medicare as a bilateral code. Like FA, its almost always done on both eyes. Nevertheless, when billing Medicare, you will need to bill the code only once, whether you perform the procedure on one or both eyes.

For Medicare, as well as for commercial payers, you should use the -52 modifier on code 92250 if you perform the procedure on only one eye. For Medicare, you will probably not get any reduction in fee, but for commercial payers you may.

Fundus Photography Denials: Check Policy Details Many private insurance payers refuse to pay for fundus photographs, code 92250 (fundus photography with interpretation and report), but look closely at the contract with the patients employerthe payer may have specified that fundus photographs are not covered. If this is the case, you can bill the patient. There have been reports from various parts of the country that commercial payers are refusing to pay for code 92250. This service, which produces color photographs of a specific part of the retina called the fundus, is important for certain conditions, such as drusen and glaucomatous cupped discs. Cynthia Huggler, COA, billing manager with Northern Eye in Alpena, Mich., has discovered that the problem is often due to the patients policy. Blue Cross/Blue Shield told us that fundus photographs are not covered in many of the commercial plans our patients have, Huggler reports. So we have to ask patients in these plans to pay for the fundus photographs. This doesnt mean the ophthalmology practice has to suffer. As Huggler says, if a plan doesnt cover a procedure, you can collect from the patient. Seventy-five percent of our patients pay at the time of service for this, says Huggler. The biggest problem, of course, is keeping track of who is paying for what. Patients always expect the ophthalmologist to know what the coverage is. We have so many types of insurance here, says Huggler. We just have to become very familiar with all of them.