Ophthalmology and Optometry Coding Alert

Question: Our doctor did a YAG laser surgery on a patient's right eye. We submitted a claim for 66821 (Discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery) linked to 366.53 (After-cataract, obscuring vision). Two months later, before the 90-day post-op period had ended, the doctor examined the other eye and found nuclear cataracts (366.04). Medicare will not pay for the exam because apparently the diagnosis codes are related. Is there any way the exam can be paid?

Ohio Subscriber
 
Answer: Yes and no. The chief complaint is vital when determining whether a visit is billable to Medicare.

If the chief complaint stated the patient was there for a postoperative evaluation of the YAG capsulotomy, and there were no complaints noted for the other eye, you don't have documented medical necessity to substantiate the billing of an unrelated office visit. Also, if the physician had previously examined the patient for cataracts and determined the patient should have surgery on both eyes, the examination may be preoperative. Medicare does not want to pay twice for the decision to perform surgery.

But if the patient had a new complaint of decreased vision in the fellow eye (which can happen after the removal of a cataract or posterior capsular membrane of the other eye), and that was documented in the chief complaint, the physician would have demonstrated medical necessity to perform and bill for an examination, using the appropriate cataract diagnosis code and modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) for the office visit.

Appeal the claim for payment by resubmitting it with the E/M documentation and a cover letter explaining the medical necessity of performing an E/M service. -- Answers to Reader Questions and You Be The Coder were contributed by Maggie M. Mac, CMM, CPC, health management consultant and national seminar leader for McVey Associates.