Ophthalmology and Optometry Coding Alert

Question: We have performed some clear lens extractions, which is an elective surgery, and have since had to perform some YAGs on these patients which is typically a covered service. How do we bill for this knowing that there will not be a cataract date to match the YAG to? Will the YAG be a covered charge? Also, we have performed some specular microscopy procedures in preparation for some LASIK procedures. What procedure code would we use for this and would this typically be a covered charge?

Minnesota Subscriber

Answer: The coverage and payment for YAG capsulotomy is not dependent upon a matching cataract surgery date. Years ago, some carriers did require that the date of cataract surgery be noted on A-scan billings in order to be paid for the testing service, but this has since been discontinued and has never been required for the billing of YAG capsulotomy.

Also, some patients have cataract surgery prior to becoming Medicare beneficiaries. In that instance, there would not be a date of the cataract surgery in the claim system. Coverage by Medicare for services is dependent on medical necessity, not on the cause of the patient's condition. In the example you have given, if the patient meets the medical necessity requirements of your carrier's LMRP (Local Medicare Review Policy), the surgery will be a covered service.

Typically, LMRPs require documentation of posterior capsular opacity, visual acuity of 20/30 or worse, or a decrease of two lines of visual acuity with glare testing, and submission of an appropriate diagnosis code with the claim. As with all services covered by Medicare, there must also be documentation of a patient complaint of a sign and/or symptom.

As for the pre-LASIK surgery testing, the CPT code that describes the service is 92286 (special anterior segment photography with interpretation and report; with specular endothelial microscopy and cell count). If the reason the test is performed is for refractive surgery, then it is not a Medicare covered service because it lacks medical necessity.