Ophthalmology and Optometry Coding Alert

Question: During the postoperative period for cataract surgery on the left eye, one of our ophthalmologists noticed that the patient's right eye - which underwent cataract surgery with an intraocular lens (IOL) one year prior - had developed a significantly cloudy posterior capsule that requires surgery. Should I code this as separate from the postoperative period of the original surgery?
     
New Hampshire Subscriber

Answer: You should report the office visit (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifiers -24 (Unrelated evaluation and management service by the same physician during a postoperative period) and -57 (Decision for surgery).
 
Append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) and modifier -RT to the surgical procedure code.
 
You should also use diagnosis code 366.53 (Cataract; after-cataract; after-cataract, obscuring vision) to show medical necessity for the procedure. Modifier -24 indicates that an office visit in a postoperative period is unrelated to the surgery. You do not need to use the eye modifiers (-LT and -RT) when reporting a procedure with modifier -24 appended.
 
Make sure you document the patient complaint for the other eye to substantiate medical necessity for the office visit and the surgical procedure.
 
Also, you may find that you carrier doesn't want to process your office visit with both modifiers -24 and -57. In that case, bill the visit with modifier -57 only.