Ophthalmology and Optometry Coding Alert

Question: My ophthalmologist calculated IOL power in both a patient's eyes. Should I report the procedure code twice using the bilateral modifiers?

New Jersey Subscriber Answer: No, you should not report the code twice. You may be tempted to report 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) twice in this situation. Basically, you might want to report 76519-RT and 76519-LT, or 76519-50 (Bilateral procedure). You may also be tempted to report 92136 (Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) using bilateral modifiers.

Reality: You should not report 76519 or 92136 bilaterally, even if the ophthalmologist calculated the IOL power of both eyes. To understand why, it's helpful to know how Medicare's Physician Fee Schedule values the procedures.

As it does with many other diagnostic tests, CMS divides the A-scan (76519) and the IOL Master (92136) into two components: the technical component (the actual performing of the test, TC), and the professional component (viewing and interpreting the results, 26).

For most procedures, the technical and professional components have the same bilateral status-- for example, 92250-TC and 92250-26 (Fundus photography with interpretation and report) are both considered inherently bilateral, marked with modifier indicator "2" on the fee schedule. The reimbursement for all components of 92250 is based on both eyes being tested.

Exception: For both 76519 and 92136, the technical component has a different bilateral status from the professional component. Both 76519-TC and 92136-TC are marked with modifier indicator "2," which means that the codes are considered inherently bilateral.

The work for performing the procedure on both eyes is included in the single CPT codes. Therefore, you should report 76519-TC or 92136-TC only once, whether the ophthalmologist tests one or both eyes.