Ophthalmology and Optometry Coding Alert

Many patients who need cataract surgery dont want to wait more than a few weeks. But sometimes, a patient wants to schedule the operation several months ahead. Maybe he or she is heading to Florida for the winter and wants to put off the surgery until the spring, for example.

If a patient comes in to schedule a cataract surgery, but wants the surgery three months after the visit, does the patient still have to be seen within 30 days prior to the surgery? asks Marilyn Prince, office manager for William J. Schwartz, MD, a Pomona, NY-based ophthalmologist. Were getting paid for the pre-op visit and for the surgery, says Prince. I cant imagine why Medicare would want to pay for another visit.

Well, no insurance company really wants to pay for anything. But there doesnt appear to be any problem with getting reimbursed for more than one pre-surgery visit. We talked to two practices about how they deal with this and other similar situations.

The first time the ophthalmologist sees a patient who has been referred by a primary care physician for possible cataract surgery, Cheryl Vovinski, billing manager for Eye Physicians and Surgeons of Western NY in Rochester, uses a consultation code (99241 - 99245) or an office visit code (99201 - 99205 for a new patient, 99212 - 99215 for an established patient). The physician examines the patient and explains the surgery during this visit. Then the patient comes back two weeks before the surgery to be measured for the lens, says Vovinski. That visit is 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation).

Sometimes the A-scan is done the same day as the initial evaluation, says Tracy Plummer, CMM, office manager for Eye Physicians and Surgeons of Western NY. It can be done that day if theyre having surgery within a few weeks, says Plummer. However, there is no coding reason why there cant be two pre-operative visits, she stresses. Some Medicare carriers may say there was no medical necessity for the second visit, since the decision for surgery was made at the earlier visit. But, there may be a clinical reason for the patient to be seen, just because the lens can change -- although usually not over a period of just a few months. Also, Medicare has no rule that the patient must be seen within 30 days prior to surgery for the A-scan.

Non-Consult Pre-Op Visit

Kimberly Fennell, CPC, assistant administrator of Baptist Eye Surgeons, a nine-ophthalmologist practice in Knoxville, TN, bills an office visit for the second visit when the A-scan is done, and has no problem getting reimbursed. She uses either a low E/M code (99212 or 99213) or an ophthalmic code (92012). Medicare may not like it; in fact, be warned that some consultants say this is absolutely wrong, and that you should be coding only the A-scan at the second visit -- if that.

(Tip: Medicare will pay for a workup in which the initial determination for cataract surgery is made, and they will pay for the pre-operative exam. But there is a time restriction: if the pre-op exam occurs on the day preceding or the day of surgery, it will be bundled with the surgery.)

As for the initial visit, Fennell uses the fourth-level office-visit code (99204) if its a new patient, and an ophthalmic code if its an established patient (92014). Thats because we give a complete exam to new patients, including dilation, and a less extensive exam to established patients she adds. We need to see what type of cataract they have.