Ophthalmology and Optometry Coding Alert

Question: Can you talk me through billing for astigmatism that was induced by cataract surgery? We've been getting denials even though we have been documenting the date of the cataract surgery. Delaware Subscriber Answer: Keep documenting the patient's history of cataract surgery when filing 65772 or 65775, but also check for appropriate diagnosis codes and the amount of time that has elapsed between the surgery that induced the astigmatism and the astigmatism repair. The first step you should take when billing 65772 (Corneal relaxing incision for correction of surgically induced astigmatism) or 65775 (Corneal wedge resection for correction of surgically induced astigmatism) is to ensure that there is thorough documentation indicating it was definitely the surgery that caused the astigmatism. This documentation must also verify that the astigmatism can only be sufficiently corrected by surgery and not by glasses, especially if the carrier is Medicare. Once you check to see that the patient's cataract surgery history has been documented, next check your ICD-9 codes to be sure you have chosen the necessary primary and secondary diagnosis codes sometimes a denial can simply be the result of switching your primary and secondary diagnosis codes accidentally.

Your primary diagnosis code should be for the astigmatism: 367.20 (Astigmatism, unspecified), 367.21 (Regular astigmatism) or 367.22 (Irregular astigmatism), depending on the type of astigmatism documented by your ophthalmologist. Your secondary diagnosis code should indicate that the astigmatism is a result of previous surgery, in this case, cataract surgery: V45.61 (States following surgery of eye and adnexa; cataract extraction status). If you are properly reporting your primary diagnosis codes and still receiving denials, you should check your carrier's policy to find out if there are any additional limitations or requirements for billing 65772 or 65775. Here are some examples of things you should look for:
Time limits. Some carriers set a time limit on how long after the initial surgery they will reimburse for a surgery-induced astigmatism. For example, a carrier might require that the repair be performed within 12 months of the initial surgery, which means if you are reporting a repair that took place 14 months after the cataract surgery, you won't be reimbursed for the repair. These time limits vary among carriers, so check each individual policy before assuming the time factor was the cause of your denial.

Astigmatism requirements. Many carriers specify the degree of astigmatism required for a procedure to be considered medically necessary and reimbursable. Other carriers stipulate the minimum amount of astigmatism and/or a significant change in the axis of the astigmatism from the precataract surgical state for the procedure to be covered. For example, a carrier might require 3.0 diopters of astigmatism or more and/or a change of 80 degrees [...]