Ophthalmology and Optometry Coding Alert

The difference could change how you code your claims.

Eye care coding often hinges on whether your physician treated both of a patient’s eyes, or if he only addressed the left or right. To make matters more confusing, some codes are inherently bilateral, while others apply only to one eye.

To stem confusion, it’s important to know not only the bilateral and unilateral coding rules, but also to get a handle on which codes can be billed twice if you address both eyes, and which can’t. Read on for a quick primer that can help you sort through these issues.

Don’t Expect Double the Payment

You could be missing out on major reimbursement for bilateral claims if you’re not clear about when to apply modifier 50 (Bilateral procedure) or the anatomical modifiers LT (Left side) and RT (Right side). However, if you report a code bilaterally, you shouldn’t expect twice the payment. Reimbursement for a bilateral service typically comes in at 150 percent of the fee schedule amount rather than at 200 percent, according to Medicare guidelines.

Before you decide which modifier best suits a given claim, you should consult the 2019 Medicare Physician Fee Schedule database, which is available on the CMS website and offers the following indicators for each code:

• 0: Bilateral surgery rules don’t apply, and you should not use modifier 50.
• 1: Bilateral surgery rules apply and you can collect 150 percent of the fee schedule amount if you use modifier 50 or LT/RT when the procedure is performed bilaterally.
• 2: Bilateral surgery rules do not apply because the code is already priced as bilateral, so you should not use modifier 50.
• 3: The standard payment adjustment for bilateral procedures does not apply and you can collect 100 percent of the fee schedule amount for each side. Typically services with a “3” refer to radiological or other diagnostic tests.
• 9: The bilateral surgery concept does not apply.
• In most cases, eye care coders will see the indicators of one, two, and three on the fee schedule. You’ll find the “0” and “9” indicators much less frequently.

Example: Your physician removes lesions from both eyelids involving more than the skin. You should report eyelid lesion removal code 67840 (Excision of lesion of eyelid [except chalazion] without closure or with simple direct closure).

When you find this code in the fee schedule database, you’ll notice a “1” in the bilateral indicator column, and you can therefore report 67840 with modifier 50 attached to it because your physician performed a bilateral procedure. You’ll find that many surgery codes have a “1” in this column.

LT and RT May Apply if Column T Lists a “0”

A “0” in column T tells you that you cannot use modifier 50. If you need to provide clarity on your claim, you may report modifiers LT or RT, either in combination or singly, but keep in mind they would be used for information purposes only and would not increase your payment.

Don’t Expect to Use 50 or LT/RT With All Codes

Often, a CPT^® descriptor will specify “unilateral or bilateral,” which can lead to confusion over whether modifiers 50 or LT/RT are necessary.

Example: Your ophthalmologist performs a corneal topography on each eye during the same session. If you refer to the 2019 Fee Schedule, CMS designates 92025 (Computerized corneal topography, unilateral or bilateral, with interpretation and report) with a “2.” Therefore, you should report this procedure with 92025, but you should not append modifier 50. The designation of “unilateral or bilateral” means the same code applies as-is whether or not the physician addressed both eyes.

A “3” in the database indicates that the code is not subject to the bilateral surgery adjustment and is paid at 100 percent for each side when you report the code with modifier 50 or LT/RT.

For example, the ophthalmologist performs a Goldmann-3 exam for a patient with flashers and floaters in both eyes. In this situation, you can report two units of 92225 (Ophthalmoscopy, extended, with retinal drawing [eg, for retinal detachment, melanoma], with interpretation and report; initial) or you can bill with the LT and RT modifiers and you’ll receive full payment for each side.

Seek Advice From Private Payers in Writing

When dealing with non-Medicare payers, you should ask your insurers how they want you to report modifiers 50 and LT/RT.

Not all private payers follow CMS guidelines. Some insurers will specify when they prefer modifier 50 and when they require modifiers LT/RT. Other payers prefer modifiers LT/RT in all circumstances because they think those modifiers are more specific than modifier 50.

Even when requiring modifier 50, some payers have different ways that they want you to report the services. Some carriers might prefer you to report your procedure code using two line items, appending modifier 50 to the second code (i.e., 67840, 67840-50). Other carriers might want the code reported only once, with modifier 50 appended (i.e., 67840-50).

Protect yourself: Always be sure to get the payers' coding recommendations and payment guidelines in writing in the event of audits or claim reviews, coding experts say.