Ophthalmology and Optometry Coding Alert

In 2005, Medicare paid ophthalmologists more than $10 million for performing two IOL calculation procedures. Our experts show you how to make sure you get your fair share.

Calculating intraocular lens (IOL) implant strength for patients facing cataract extraction is a straightforward part of most ophthalmologists' workloads -- but the rules for coding and billing these procedures are far from simple. When a patient is facing cataract extraction with IOL insertion, an ophthalmologist must often perform either an A-scan or an IOL Master measurement to determine the type and power the IOL should be.

Medicare divides these procedures into technical and professional components and has set rules about which components you can -- and cannot -- report bilaterally. And if you're sharing the work with an optometrist, your coding task is even more complex.

The IOL Master (92136, Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation), or optical coherence biometry (OCB), is becoming the gold standard for IOL measurements. OCB is a more advanced way of calculating IOL power than the A-scan (76519, Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation). But there are cases (such as mature cataracts) that require ultrasound echography instead of OCB.

Key: Medicare divides both 76519 and 92136 into two components, says Judy Seymour, ACS-OH, coder and biller for Eye Associates of the South in Biloxi, Miss. Each code contains a technical component, marked by appending modifier TC (Technical component), and a professional component, which you indicate with modifier 26 (Professional component).

The Medicare Physician Fee Schedule assigns CPT codes modifier indicators that determine how Medicare reimburses codes that coders report bilaterally. Snag: The professional component of the IOL Master has a different bilateral status than the technical component. The same is true for the components of the A-scan procedure.

The fee schedule marks the technical components of both 76519 and 92136 with modifier indicator "2." That indicator means that the code already specifies a bilateral procedure, says Melissa Woods, CPC, coder and biller with Advanced Eye Care in Alexandria, Va.

The single CPT codes include the work for performing the procedure's technical component on both eyes -- you should report 76519-TC or 92136-TC only once, whether the ophthalmologist examines one or both eyes. Ophthalmologists typically perform the procedure's technical component (the actual measurement of the eye) on both eyes at the same time.

On the other hand, the fee schedule marks the professional components (76519-26 and 92136-26) with modifier indicator "3," which means that the codes are inherently unilateral.

Although the ophthalmologist performs the technical component on both eyes, he may calculate the IOL power only for the eye that will receive the IOL. One unit of 76519 or 92136 without modifiers, therefore, includes the following:

• the technical work involved in measuring both eyes, and

• the professional work involved in IOL power calculation for one eye.

So if the ophthalmologist performs the complete test on both eyes and calculates the IOL power in one eye, code one unit of 76519 or 92136 without modifiers TC or 26. The unmodified code accurately represents the work you performed. Based on the unadjusted national Medicare Physician Fee Schedule and the 2008 conversion factor (38.0870), payment should be $77.70 for 76519 and $82.27 for 92136.

If the ophthalmologist calculates the IOL power in both eyes, you would need to bill on two lines, reporting the technical and professional components depending on guidelines set by your local carriers like this:

• 76519-26-50 or 92136-26-50 on one line; or

• 76519-26-RT (Right side) and 76519-26-LT (Left side) on separate lines; or

• 92136-26-RT and 92136-26-LT on separate lines.

• 76519-TC or 92136-TC.

Appending modifier 50 (Bilateral procedure) to the professional component of these procedures, showing that the ophthalmologist performed this usually unilateral procedure bilaterally, should double your reimbursement. The fee schedule values the professional components of both 76519 and 92136 identically, at 0.77 relative value units (RVUs). Reporting either code bilaterally should yield 1.54 RVUs, which yields $58.65. Adding that to the technical component RVUs (1.27 for 76519 or 1.39 for 92136) brings your total to $107.02 for 76519 or $111.59 for 92136.

Do this: Be certain to check reimbursement amounts. Occasionally, a payer will overlook modifier 50 and underpay the service.

If, however, an optometrist performs the technical component of 76519 or 92136 on both eyes, and your ophthalmologist interprets the test and calculates the IOL power for one:

• Ophthalmologist: One unit of 76519-26 or 92136-26.

• Optometrist: One unit of 76519-TC or 92136-TC.

The ophthalmologist would earn $29.33 for either procedure, and the optometrist would earn $48.37 for 76519-TC or $52.94 for 92136-TC.

If your ophthalmologist calculates IOL power for both eyes and the optometrist performs the technical component for both eyes:

• Ophthalmologist: One unit of 76519-26-50 or 92136-26-50 (or the alternative reporting with RT/LT described above).

• Optometrist: One unit of 76519-TC or 92136-TC.

The ophthalmologist would earn $58.65 for either procedure. The optometrist would earn $48.37 or $52.94.

What if the ophthalmologist has to perform both an A-scan and an IOL Master? Should you report both 76519 and 92136? No, says the Correct Coding Initiative. Codes 76519 and 92136 are in a mutually exclusive bundle. If you report both codes, Medicare carriers will pay you only for 92136.

Example: The ophthalmologist performs the technical portion of an A-scan on the left eye, but dense cataracts prevent him from getting a viable result from the right eye. He performs an IOL Master on the right eye and calculates IOL power for the right eye. You can only report one unit of 92136-RT for the right eye.