Ophthalmology and Optometry Coding Alert

Question: We recently purchased the Retina Tomograph II. I know that the procedure code is 92135 and is unilateral. Do you receive full reimbursement for both eyes, or is it 100 percent for the first and 50 percent for the second? Would I bill this as 92135-50? Also how do you code a subsequent 92135? Do you use a -26 modifier? What is considered subsequent? More than one a year or every time after the initial 92135?

Georgia Subscriber


Answer: You are correct, 92135 (scanning computerized ophthalmic diagnostic imaging [e.g, scanning laser] with interpretation and report, unilateral) is a unilateral code in the Medicare program. As a unilateral code, when two services are billed to Medicare, both services are supposed to be approved at 100 percent of the fee schedule amount. Most Medicare carriers do prefer that you bill the services as one line item with the -50 modifier (bilateral procedure), 92135-50, but check with your carrier to be sure.

Typically, when -50 is applied to a code, the claim system generates an approved amount of 150 percent. Only a handful of codes have an approved amount of 200 percent. Be careful to review the explanation of Medicare benefits (EOMB), to make sure the carrier has approved the services for a total of 200 percent, not 150 percent. If the carrier is paying only 150 percent when you submit a single line-item with the -50 modifier, then change your billing protocol to a two line-item entry: 92135-RT and 92135-LT.

In regard to subsequent testing, use 92135; a modifier is not required. When billing for subsequent testing services, making a distinction that the service is initial or subsequent is not necessary. In ophthalmology, we only have one testing service that has the language initial and subsequent, extended ophthalmoscopy codes 92225 and 92226. Regarding frequency, most Medicare carriers have established a local medicare review policy (LMRP) for 92135. Most policies allow for a combination of optic disk scanning and visual field testing during a calendar year, depending on the patients condition. Contact your local Medicare carrier for its LMRP.

Answers for You Be the Coder and Reader Questions provided by Catherine Brink, principal at Health Care Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J.; Lise Roberts, vice president of Health Care Compliance Strategies, a coding and compliance consultant based in Jericho, N.Y.; Raequell Duran, COA, president of Practice Solutions, a Bakersfield, Calif.-based coding and reimbursement consulting firm; and Sherry Searson, CPC, an independent coding consultant based in Charleston, S.C.