Ophthalmology and Optometry Coding Alert

Question: If we do 68840 (probing of lacrimal canaliculi, with or without irrigation) bilaterally and charge $185 per eye, why does Medicare pay only for one eye?

Idaho Subscriber

Answer: This code will pay the same whether you perform the procedure on one or both eyes. Medicare determines what amount to pay for a service when it is performed on both eyes by looking at the procedure codes bilateral indicator. Procedure code 68840 has a bilateral indicator of 0 which means that the 150 percent payment adjustment does not apply. If the procedure is reported with modifier -50 (bilateral procedure) or with modifiers -RT and -LT, the carrier is to base payment for the two sides on the lower of: (a) the total charge for both sides or (b) 100 percent of the fee schedule amount for a single code. For example, lets say the fee schedule amount for a code is $125. The physician reports the code with the -LT modifier with an actual charge of $100 and the code with the -RT modifier with an actual charge of $100. Payment would be based on the fee schedule amount ($125) since it is lower than the total charges for the left and right sides ($200). This means that when you perform a procedure with a bilateral indicator of 0 for both eyes on the same day, the single payment includes payment for both eyes.