Ophthalmology and Optometry Coding Alert

Question: Weve had problems getting reimbursed for A-scan and B-scan ultrasonography (76512, 76519) when done on the same day. Medicare is not the problem; the problem is HMOs. They claim the A-scan is part of the B- scan. We document that the B-scan is done to evaluate the retina in the presence of a dense cataract, and that the A- scan is to calculate the IOL power prior to cataract surgeryto no avail. Any suggestions, other than bringing the patient back twice?

B. Kutner, MD
Yardley, PA

Answer: These codes76512 and 76519are not connected and should not be regarded as such by HMOs. Yes, 76512 (ophthalmic ultrasound, echography, diagnostic; contact B-scan [with or without simultaneous A-scan]) is connected to 76511 (ophthalmic ultrasound, echography, diagnostic; A-scan only, with amplitude quantification), so if the ophthalmologist bills 76511 and 76512, the insurer would not pay for both. However, 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) is a different code altogether. The IOL calculation A-scan is not for diagnostic purposes; rather, it is for measurement before cataract surgery. On the other hand, the B-scan, done to look at the retina if there is a very dense cataract, is diagnostic.

First, check to make sure you are using either the dense cataract diagnosis, 366.xx, for both services or, better yet, a retinal/macular diagnosis for the B-scan. If medical necessity for both services is documented and the ICD-9 code(s) is appropriate, then the problem is that the payer doesnt understand that the simultaneous A-scan described in 76512 is not performed at all. You will need a cover letter that describes the differences in instrumentation, the meaning of simultaneous, and the medical necessity for doing both distinct services in the presence of dense cataract to file with these claims.

Another short-term approach to solve this payment problem is to get pre-procedure authorization from the HMO while the patient is waiting. One practice tells us that all the HMO charts are red so they are easily identified. That way, if an ophthalmologist needs a B-scan, the red chart comes out and the HMO is called before anything is done.

A long-term approach would be for the ophthalmologist to call the HMOs medical director. The HMO claims processing will cause a denial for one of two reasons. Either the HMO has installed a computerized edit program that inappropriately has identified 76519 as a component part of 76512, or a human claims processor is following a claims edit rule established by the HMO without understanding the codes or the procedures.

Usually, only the medical director can change such reimbursement policies. The call may take come work to set up, but the time and effort are worth it if the result is appropriately paid claims without the need for cover letters and prior authorizations.