Ophthalmology and Optometry Coding Alert

Question: The ophthalmologist performed bilateral retinal tear repair (67145) on a Medicare patient. The first claim I submitted was 67145-RT, 67145-LT. When the payer denied it, I resubmitted using 67145-RT and 67145-LT-51, but it was also denied. What is the best way to report the repair for reimbursement?

Georgia Subscriber

Answer: Medicare Part B requires that you submit all bilateral surgical procedures on a single line with modifier 50 (Bilateral procedure), so report 67145-50 with a “1” in the unit field and double the charge. Medicare will pay 150 percent of the allowable.

If billing commercial insurance, make sure to verify your payer’s reporting guidelines, because when you don’t bill the correct codes and modifiers, you may be denied payment, or payment may be 100 percent of the allowable rather than the correct 150 percent. Commercial payers will vary in their requirements. Some may prefer two lines with modifiers RT (Right side) and LT (Left side).

Also, you may not need to append modifier 51 (Multiple procedures), as most payers’ systems are sophisticated enough to recognize multiple procedures in the same setting.