Ophthalmology and Optometry Coding Alert

Question: We are having problems getting reimbursed from certain HMOs when an A-scan (76519) is done the same day as a B-scan (76512). The insurers say the
A-scan is part of the B-scan. Medicare pays both without problems. Suggestions?

Anonymous Pennsylvania Subscriber

Answer: HMOs can indeed create a problem here. The problem is that 76519 is for ophthalmic biometry by ultrasound echography, A scan; with intraocular lens power calculation and 76512 is for ophthalmic ultrasound, echography, diagnostic; contact B-scan (with or without simultaneous A-scan).

Note: Code 76512 does not include an axial length measurement with the intraocular lens power calculation which is essential to the implant for the cataract surgery.

The A-scan that is included is 76511 which is a diagnostic A-scan that only looks at one dimension. The
B-scan looks at two diagnostic dimensions. So it would technically be possible to do the diagnostic A-scan in conjunction with the B-scan. CPT describes a simultaneous A-scan as being part of a B-scan but fails to specify that it is a diagnostic A-scan that is included. The doctor needs to measure the eye for the IOL, doing an A-scan that pinpoints the length of the eye and is not scanning for a lesion, for example. This type of A-scan is always done separately from a B-scan and not simultaneously.

When a B-scan must be done for a certain type of cataract, for example, a very mature cataract in which the lens is opaque and obscuring visualization of the posterior pole, it should be paid in addition to the biometric A-scan. The B-scan might also need to be done if the patient has miotic pupils preventing the performance of an adequate indirect examination of the retina.

It should be enough to use the diagnosis code 366.17 (total or mature cataract) to be reimbursed for the B-scan. But if the HMO doesnt understand that the procedure code 76512 does not include the axial length measurement for the IOL which is part of the code 76519, someone is going to have to explain it to them. Its recommended that you try to obtain guidelines from HMOs on ophthalmic procedures because this will aid your filing. Many ophthalmologists have a hard time collecting from HMOs for an A- and B-scan, but our sources stress that this shouldnt be the case.