Ophthalmology and Optometry Coding Alert

Question: Some of our cataract surgery patients develop increased pressure after the operation. Can we bill Medicare for treating increased intraocular pressure within the global period of cataract surgery?

Missouri Subscriber
 
 Answer: The elevated intraocular pressure (IOP) is usually not related to the cataract surgery, especially if it existed prior to the surgery.
 
For example, if a patient has glaucoma that is not well-controlled and you've been having difficulty managing the pressure medically, the cataract surgery will not repair the problem. The two are completely unrelated. If the purpose of the visit is to manage an ongoing and unstable glaucoma that existed prior to the cataract surgery, it is considered unrelated to the cataract surgery and is covered.
 
Or, if during the previous few years the physician has been monitoring progress of field loss and other conditions related to glaucoma, a regularly scheduled visit for glaucoma that happens to take place in the global period of cataract surgery is covered. This is because the glaucoma is unrelated to the surgery. 
 
You can bill for monitoring a patient with glaucoma that is controlled if the IOP check was a previously scheduled recheck and if it was not added on to a postoperative visit.
 
The prescheduled glaucoma visit would clearly be dealing with both eyes, not just one. If the progress note says it was a glaucoma check, the primary diagnosis must be one of the glaucoma codes (365.xx), with an OU (both eyes) indication in the notes. Also, the documentation must focus on the glaucoma condition and not the recent cataract surgery.
 
The visit is definitely not covered if the increased IOP is related to the cataract surgery, which can cause a temporary spike in IOP. Such spikes are most often due to the viscoelastic material used to protect the cornea when the IOL is inserted. In some patients, the IOP elevates because the viscoelastic material causes the trabecular meshwork to operate less efficiently. Pressure spikes also occur when ophthalmologists prescribe eye drops that contain a steriod for postoperative care. Some patients are steroid responders, which means they get a spike in their IOP that will usually stop when the medication is stopped. These cases of IOP elevation are related to the cataract surgery, and therefore are covered by the global period of cataract surgery included in the global surgery fee.
 
One significant difference between a postoperative visit for cataract surgery and a visit to check uncontrolled IOPs, or glaucoma, is that the cataract visit will show only one eye involved, while glaucoma affects both eyes. If your documentation refers to IOP in one eye only the eye that was operated on you should not bill separately for the visit.
 
Document the purpose of the visit carefully. If you document the visit as a postoperative visit, you can't bill it. If you document it as glaucoma-related which means the chief complaint is glaucoma that is not well-controlled or that this is a regularly scheduled glaucoma recheck an auditor will see that it was appropriate to bill.

Reader Questions and You Be the Coder were answered by Raequell Duran, president of Practice Solutions, ophthalmology coding and compliance consultancy, Santa Barbara, Calif.; and Lise Roberts, vice president of Health Care Compliance Strategies in Jericho, N.Y.