Ophthalmology and Optometry Coding Alert

Question: Are insurance companies allowed to reduce our fees for multiple procedures performed during the same session? Should I reduce the fee before sending the claim?

California Subscriber

Answer: Many ophthalmic tests are paid at 100 percent each when the ophthalmologist  performs the services bilaterally. The payments are not subject to a reduction. Become aware of what those procedures are and how payers should reimburse for them. Also, keep in mind that you should double a procedure billed with modifier 50 to indicate both eyes to ensure proper claim processing and payment.

If you need to apply modifier 51 (Multiple procedures) to a surgical code, then you'll be facing multiple-procedure fee reductions. Many payers, including Medicare, follow a reduced fee policy for multiple procedures performed during the same operative session. Generally, the policy looks something like this:

• Procedure 1 is paid at 100 percent of the allowable.

• Procedure 2 is paid at 50 percent of the allowable.

• Procedure 3 is paid at 25 percent of the allowable (for some payers) and 50 percent of the allowable (for some payers).

Important: Even if the payer follows a multiple procedure reduction policy, youshould not reduce the fee before you send your claim. Let the payer reduce the fee.

You don't want to reduce your fee and then have the payer reduce it again.

-- Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla.