Ophthalmology and Optometry Coding Alert

Question: When my ophthalmologist sees a patient for a preoperative exam before cataract surgery on one eye, he sometimes finds that the other eye needs to be done as well. He schedules the patient to come back for another pre-op exam during the post-op global period of the first cataract surgery. Can I code an E/M service with modifier -24 for the second pre-op exam?

South Carolina Subscriber

Answer: No. Once the decision for surgery has been made, office visits are inclusive and nonbillable - even if you append modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) - unless the patient is presenting with a different problem. Medicare will deny your claim, and most carriers maintain that you cannot bill a visit within the cataract surgery postoperative period for the decision to perform a similar procedure on the other eye.

Most carriers think the ophthalmologist had already decided that the second eye needed treatment when he decided to perform surgery on the first eye. Thus, they think, he has already performed the preoperative exam on the second eye, and they interpret the second visit instead as postoperative care for the first eye.

Exception: While you may not be reimbursed for your E/M service, your carrier will pay for the cataract surgery, and you should use the eye modifier to do so.

You should report the procedure (CPT codes 66830-66986) with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) and the appropriate eye modifier if done within the global period of the first cataract surgery.

If you billed for the first procedure with the appropriate eye modifier, you should receive the full Medicare fee schedule amount for the second procedure.