Ophthalmology and Optometry Coding Alert

Question: I'm trying to submit a claim for 76514 performed on both eyes, but I've been getting conflicting information. One payer representative told me to code 76514 on two lines, appending modifiers LT and RT. Another one said that it's already considered a bilateral procedure and that I should only code it once. Another coder told me to append modifier 50 (Bilateral procedure). What's the proper way?

Nebraska Subscriber

Answer: You should only code it once without any modifier. The Physician Fee Schedule Database gives 76514 (Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral [determination of corneal thickness]) a bilateral surgery indicator of "2," which means "150 percent payment adjustment for bilateral procedure does not apply."

Note: The code description for 76514 includes the phrase "unilateral or bilateral," which appears in many procedure codes. This phrase means that Medicare -- and most payers -- will pay the same whether you perform the procedure on one or both eyes.

By the same token, if you perform the test on only one eye, it is not necessary to append modifier 52 (Reduced services) to the CPT code. Keep in mind that a local Medicare payer may require modifiers LT or RT when billing a bilateral code for one eye only. But that is not typical and you should not append modifier 52 for a service that is defined as either unilateral or bilateral unless a local carrier determination exists and advises you to do so.