Ophthalmology and Optometry Coding Alert

Question: Why am I not receiving payment for treating cystoid macular edema (CME) after cataract surgery?

Florida Subscriber

Answer: You may be getting denials for treatment of CME due to medical necessity, which is correctable by sending in documentation, or due to a carrier interpretation that any office visit in a postoperative period is not billable in other words, that all postoperative visits are part of the global surgical package. The second reason presents a more difficult problem. Determining the cause of the denial is the first step.
 
Medical necessity: If the claim is denied for medical necessity, your carrier may have put in a system edit to deny claims that are billed with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period). In Northern California, the carrier put in a system edit to do that. Although that edit has been removed, the carrier felt that the majority of claims billed with modifier -24 did not meet the criteria for payment. In other words, they felt they were being billed for services that were not truly "unrelated." They didn't stop paying the claims, but instead put the burden of proving medical necessity on the providers. When the edit was in place, providers had to submit medical records to get the claim paid or write off the visits if their documentation was inadequate.
 
Global period: If your carrier is denying payment stating that the services you have billed are included in the global surgical package, and you have appended the correct modifier, you have a different problem. Technically, modifier -24 ensures payment for an office visit within the postoperative period for examination of a diagnostic condition that is unrelated to the surgery. However, some carriers are disregarding modifier -24; in other words, visits during the postoperative period are not paid, period.
 
Modifier -24 is an easy target. The physician has already received a fee for the surgery, which includes related postoperative visits. With modifier -24, the patient has not gone to the operating room, but is treated in the office. Who is to say what is "related" and what is "unrelated"? If a carrier wants to say that any possible complication of surgery is inherently "related" and therefore not payable outside of the operating room (OR) within the postoperative period, no individual ophthalmologist can successfully argue against that. Perhaps a local or state ophthalmological association would have the clout to convince a carrier otherwise.
 
With CME, it is not just the office visit at stake, but also the procedure. CME may be managed by retrobulbar injection of Kenalog or another anti-inflammatory drug. Some carriers may take the approach that if the condition can be treated in the office instead of in the OR, it's related to the prior surgery and can't be billed. This would explain why they pay for treatment of retinal detachment in the postoperative period of cataract surgery although it is considered by most clinicians to be a complication of cataract surgery. What is related and what is not related according to Medicare carriers does not depend on medical classification so much as payment rule classification.