Ophthalmology and Optometry Coding Alert

Question: A patient had a laser treatment. He returned for a follow-up visit a week later, and the doctor decided to perform cataract surgery. The preoperative and A-scan were performed on the same day. How should I code for this visit?

Florida Subscriber

Answer: If the documentation for the visit was focused on the cataract vision complaints and not the postoperative care, bill an office visit (99212-99215) with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period). Link the appropriate cataract diagnosis (366.00-366.9). Report the A-scan with 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) with the eye modifier -RT or -LT appended to indicate right side or left side.

  Answers to You Be the Coder and Reader Questions contributed by Lise Roberts, vice president, Health Care Compliance Strategies, Jericho, N.Y.; and Raequell Duran, president, Practice Solutions, Santa Barbara, Calif.