Ophthalmology and Optometry Coding Alert

When evaluating a patient who had cataract surgery in one eye, code the visit for the second eye based on carrier rules. There's no national policy regarding this visit. Some payers will cover it, based on medical necessity.
 
Many payers don't allow billing the visit at all. They say the second eye was evaluated when the first was examined; hence, the preoperative evaluation was already performed.
 
Even though there are two surgeries, you don't get paid for two decisions for surgery. You make the decision for both at the same visit, the initial one.

For example, a patient has bilateral cataracts. At the initial evaluation, during which the ophthalmologist determines that the reason the patient's vision is deteriorating is cataracts in the eyes, the physician and patient agree that one eye will be operated on first and the second eye will be operated on later. During the first surgery's postoperative period, the ophthalmologist evaluates the patient for the second surgery. Is the visit primarily for postoperative care for the first surgery, or for examining the second eye? It's probably for both, which would technically, at least allow appending either modifier 24 (unrelated E/M service by the same physician during a postoperative period) or -57 (decision for surgery), says Melissa K. Duchak, CPC, practice administrator for Bruce E. Kanengiser, MD, an ophthalmologist in Piscataway, N.J. But many carriers say this visit in which you evaluate the second eye is actually a postoperative visit for the first eye. You can't bill for it.
 
The carriers that normally don't pay for the second evaluation within the postoperative period of the first surgery established two criteria for covering that visit: (1) new symptoms in the second eye, or (2) a significant change in health that requires a new preoperative examination. If at least one of the criteria is not satisfied and the visit for the second eye is within the postoperative period of cataract surgery for the first eye, you will not get paid. These carriers also demand that all documentation supporting these indications be submitted with the claim.
 
Most often, both eyes need cataract surgery, and the second eye is done within 90 days of the first. Typically, the patient is so happy with the first eye that he or she doesn't want blurry vision in the other eye and requests the additional surgery as soon as possible. Assuming all the medical-necessity criteria are met for cataract surgery on the second eye, it is usually operated on within the 90-day global period of the first eye.

Some Medicare carriers are more generous, and say that an E/M code, usually 99213 (level-three established patient office visit), should be used prior to planned cataract surgery in the contralateral eye, when an exam (92002-92014 or 99201-99215) has already been performed prior to the first cataract extraction. They feel that the eye codes are not suitable for the second evaluation, although payment for an intermediate eye exam is about the same as payment for 99213.

What if a patient has a postoperative visit for some other kind of surgery, and during that postoperative visit, a cataract evaluation is done? For example, a patient had a trabeculectomy. During a postoperative visit, the physician discovers a cataract in the other eye. "This will be a separate and distinct evaluation from the postoperative visit," says Ramona Cosme, president of Ramco Medical Billing, an ophthalmology reimbursement and billing firm based in Edison, N.J. "You must bill the visit with modifier -24 to get it paid." Use a cataract diagnosis (366.xx), not the glaucoma diagnosis (365.xx), for the office visit. You won't need -LT (left side) or -RT (right side), because the diagnosis will clearly show that the service is separate and distinct from postoperative care for the trabeculectomy.

Frequency

Some carriers say the maximum time between the preoperative examination and the date of surgery is three months, due to possible changes in the patient's health or vision.
 
There is no national policy about how frequently A-scans should be performed either, or how soon prior to surgery. It depends on the carrier. Most carriers will allow billing of the professional and the technical component after a year. Remember that medical necessity must exist for repeating the technical component.

Bill 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) if you are planning a cataract extraction with IOL insertion. B-scans (76512, ophthalmic ultrasound, echography, diagnostic; contact B-scan [with or without simultaneous A-scan] or 76513, anterior segment ultrasound, immersion [water bath] B-scan or high resolution biomicroscopy) are usually covered only if the patient has a dense cataract, which makes it difficult to see the posterior segment of the eye. Code 76516 (ophthalmic biometry by ultrasound echography, A-scan) is usually not payable if the only diagnosis is cataract.
 
At the first evaluation, bill 76519. Prior to the second surgery, bill 76519-26 (professional component) for the second eye if it is done within one year of the first eye. The technical component is bilateral for 76519 and 76516.