Ophthalmology and Optometry Coding Alert

Question: The doctor did a limbal relaxing incision for astigmatism at the time of cataract surgery. Is there a way to add this charge to the cataract surgery chart? What is the correct CPT code?

California Subscriber

Answer: Medicare pays for the correction of astigmatism during cataract surgery when the astigmatism procedure is used to treat specific lesions of the cornea that deal with the abnormality of the eye or for the correction of surgically induced astigmatism. When performed for the correction of surgically induced astigmatism, the astigmatism must represent a significant change from the patients preoperative and postoperative refraction. If, in the above example, the patients astigmatism was not the result of surgery or a corneal lesion, Medicare will not reimburse for the service. To have the patient pay for the procedure, have him or her sign an advanced beneficiary notice.

An advanced beneficiary notice says the following: Medicare will only pay for services that it determines to be reasonable and necessary under Section 1862(a)(1) of the Medicare law. If Medicare determines that a particular service, although it would otherwise be covered, is not reasonable and necessary under Medicare program standards, Medicare will deny payment for that service. In your case, Medicare is likely to deny payment for [specify particular service(s)] for the following reasons: [state the reason(s) for your belief]. Then, the patient must sign a beneficiary agreement, which says the following: I have been notified by my physician that he/she believes that, in my case, Medicare is likely to deny payment for the services identified above for the reasons stated. If Medicare denies payment, I agree to be personally and fully responsible for payment.

To bill the service to Medicare for a denial so you can bill the patient, code the relaxing incision as 65772 (corneal relaxing incision for correction of surgically induced astigmatism), with the diagnosis code 367.21 (regular astigmatism). For surgically induced astigmatism, use diagnosis code 998.89 (other specified complications of procedures, not elsewhere classified; other specified complications) for astigmatism, postoperative (general), or 996.51 (mechanical complication of other specified prosthetic device, implant, and graft; due to corneal graft) for astigmatism, postoperative (keratoplasty).

Also, if the incision was performed for surgically induced astigmatism or corneal lesion, contact your Medicare carrier for their local policy. They most likely will require that you indicate the number of diopter changes between the patients preoperative and postoperative refraction in Box 19 or comments area of the claim form.