Ophthalmology and Optometry Coding Alert

When two ophthalmologists are performing surgery on the same patient at the same time, doing two separate procedures, what modifier should you use so they can both get paid? We regret to report that the answermodifier
-80 (assistant surgeon) or -81 (minimum assistant surgeon)wont always help you.

Take the case of Francois D. Trotta, MD, of Boise, ID, who assisted at a surgery of a Medicare patient who needed a lensectomy (66940) and a posterior vitrectomy (67036). A different ophthalmologist performed the lensectomy; Trotta, a retinologist, did the posterior vitrectomy. Both surgeons remained with the patient during the entire process, writes Janet Meyers, Trottas office manager. Which modifier should be used?

Unfortunately, it doesnt matter which of these two modifiers you use, because Medicare wont pay for these two procedures to be done together, reports Patricia Santos, billing supervisor for Charles White, MD, of Wareham, MA. Youll only get paid for doing one of those, says Santos. This is because there is one code that includes both of these procedures when both are performed pars plana (66852). The payer turndown does not relate to the procedures being bundled under the Correct Coding Initiative (CCI). Medicare requires that if there is one code that includes the parts of a procedure, you may not use two or more codes to describe the procedure. However, it is often true in these cases that the lens is removed by phacofragmentation (66850) and not by the pars plana method. Getting the codes and modifiers right for these scenarios is crucial to correct payment.

Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY, has the following advice on how to code several related scenarios involving two surgeons during the same procedure.

1. Two surgeons, two pars plana procedures.
If both procedures were performed pars plana and two surgeons were medically necessary to perform the case, then the -62 modifier (two surgeons) for co-surgery applies and not the -80 or -81. Each surgeon will submit a bill that looks exactly the same: 66852-62. Medicares payment policy for co-surgery is to allow 125 percent of the normal Medicare Fee Schedule and divide the payment equally (50/50) between the two surgeons. One operative report can be dictated by either surgeon as long as it lists both surgeons as primary and the body of the operative note reflects clearly which portions of the procedure each surgeon performed, Roberts says. Also, since medical necessity for two surgeons is an issue in these cases, an indications section at the beginning of the report may be useful to make the medical necessity issues clear.

A well-dictated operative report is crucial because these claims are often denied or one is paid and the other is denied initially. In the case of denial, you will need to go through the Medicare appeals process by first submitting the denial for review and then (if still denied after the review) requesting a fair hearing. These are typically settled at the fair hearing level of appeal if the operative report was well dictated.

2. Two surgeons, two surgical approaches. If the lensectomy was performed by phacofragmentation, then each surgeon should submit a bill for the procedure he or she performed:

Surgeon A: 66850 (phacofragmentation)
Surgeon B: 67036 (vitrectomy, mechanical
pars plana approach)

Neither of these two codes is either a mutually exclusive bundle or a more comprehensive bundle under the latest edition of the CCI. Each surgeon should dictate an operative note for the procedure he or she performed. Also, both of these procedures allow for an assistant at the surgery if medically necessary, according to the Medicare Fee Schedule payment indicators.

3. Both surgeons assist each other. If there is medical necessity that can be made clear in the indications section of the operative report, then each surgeon could also bill a surgical assist (modifier -80) on the procedure for which he or she was not the primary surgeon:

Surgeon A: 66850 and
67036-80
Surgeon B: 67036 and
66850-80

Again, the assistant billings will often be denied, which will require going through the appeals process to resolve. This makes well-dictated operative reports especially important, Roberts stresses.

4. Two surgeons, two procedures. Another scenario is an intraocular lens (IOL) exchange (66986) with a posterior vitrectomy (67036). Neither of these two codes is bundled with the other under the CCI. The billing would be similar to the second scenario:

Surgeon A: 66986
Surgeon B: 67036

5. Each surgeon assists the other. If it were medically necessary to assist on each others proceduresthe two procedures in scenario 4then the billing would be (with the same provisos regarding well-dictated operative notes and going through the appeals process indicated in scenario three):

Surgeon A: 66986
67036-80
Surgeon B: 67036
66986-80