Ophthalmology and Optometry Coding Alert

Question: How can we bill a pre-op exam for a cataract surgery when its the second eye and being done in the post-op of the first eye? Currently we are billing 99212 with a -24 modifier (unrelated evaluation and management service by the same physician during a
postoperative period) to indicate the visit is unrelated to the prior surgery. But because the diagnosis is usually the same, Medicare has been denying our claims and including them in the global of the first surgery. Is there any other way we can bill the pre-op exams on the second eye during the post-op of the first eye?

Editors Note: This is a case of a patient who was so happy with the first cataract operation that he or she wanted the second one done right away. The ophthalmologist had already filed for both A-scans.

Nancy Gould
Diablo Valley Eye Center
Walnut Creek, Calif.


Answer: If you are only coding an office visit, and the diagnosis is cataract, its not going to be paid during the global period. True, its a different eye. But its still a cataract, and Medicare considers that if the second surgery is done in the global period of the first surgery, it means the determination that both eyes were ready for surgery was made before the first eye was operated on. Under these circumstances, Medicare believes the visit for the second eye is the preoperative visit that should be included in the global package for the second eye even though it may occur more than one day before the surgery takes place.

But Medicare has specific requirements for how to go about filing for cataract exams for first and second eyes. Cataract evaluations usually include A-scans (76519). Medicare prefers that the technical componentthe actual ultrasoundbe done on both eyes even if only one is going to get cataract surgery. Then, before the second eye is operated on, the professional component (the IOL calculation) for that eye would be filed.

Note: This is the only ophthalmology service that has one payment policy for the technical component and one for the professional component.

You are only allowed to do an A-scan every so oftenonce a year is a common carrier rule. So for the first cataract evaluation, you would bill 76519 with no modifier; this would include the technical component for both eyes and the professional component for one eye. Then, when you decide its time to operate on the second eye, you would bill 76519-26 (professional component). And if, as in the scenario above, this decision is made during the post-op period of the first surgery, you would also bill modifier -79 (unrelated procedure or service by the same physician during the postoperative period) to indicate that the service is unrelated and during the post-op period. It is also a good idea to use the -LT and -RT modifiers.

Note: If the patient came in during the post-op period of the cataract surgery on the first eye, and the diagnosis was conjunctivitis, for example, you should not have a problem being paid for the 99212, as long as you use the modifier -24, which is specifically for an evaluation and management service provided within the post-op period.