Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist is seeing a patient for follow-up visits after another physician performed eye surgery on her while she was in Connecticut for the summer. Now that she’s here in Florida for the winter, we’ve taken over care for our office visits, but Medicare denies the claims even when we included modifier 55 for postoperative management only. How should we handle this situation?

Florida Subscriber

Answer: Verify the surgical procedure and CPT^® code reported by the initial surgeon so you can include the same code on your claim with modifier 55 (Postoperative management only) attached to that surgical code. Your physician should be paid approximately 20 percent of the allowed amount for the primary CPT^® code reported.

No E/M code: Postoperative visits related to the surgery are included in the surgical procedure code, so don’t bill an office visit such as 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). That’s why you’ll submit your claim with the original surgical code and modifier 55. You may also want to confirm that the original ophthalmologist didn’t bill the global fee for the surgery—he should have appended modifier 54 (Surgical care only) to the surgical code. If he didn’t, then he collected the full fee and Medicare won’t pay another doctor for postoperative surgical care.

Caution: CPT^® includes 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure) for related postoperative visits within the global period. Although your ophthalmologist is seeing the patient postoperatively, don’t report 99024 -- it’s reserved for postop visits with the operating surgeon.