Ophthalmology and Optometry Coding Alert

Proper billing of modifier 26 (professional component) and modifier -TC (technical component) is essential to getting paid in full and avoiding fraud charges when filing claims for fundus photography (92250).

If you do not append modifiers to 92250 (fundus photography with interpretation and report), the professional and technical components are included in your claim, explains Kitty Timmes, COMT, office manager for Joseph J. Timmes Jr., MD, a retinologist who practices in Annandale, Va.

But if you perform the interpretation and are not taking the photographs, you can bill only for the professional component by appending modifier -26 to 92250.

For example, if an ophthalmologist doesnt have the equipment to perform fundus photography in the office, he or she sends the patient to the hospital, which takes the photographs. When the hospital sends the photos back, the physician interprets them, but because the ophthalmologist didnt perform the photography on equipment he or she owns the coder can bill for the professional component only: 92250-26. The hospital will bill for the technical component: 92250-TC. If you only perform the professional component and file 92250 with no modifier, you will be committing fraud because your claim will imply that you took the photos and interpreted them.

Paying the Facility

The other option, according to Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based reimbursement, coding and compliance consulting firm, is to pay the facility performing the photography a fee for taking the fundus photo, and then bill the entire service with 92250 and no modifiers attached. When doing this, be sure to indicate on your claim that an outside lab was used and that the facility has agreed not to submit a bill for the technical portion of the service.

Durans suggestion may not work with all carriers. Check with yours first. Some payers require two-line item billing, using either the -TC or a local carrier-specified modifier that indicates a purchased diagnostic test was involved, notes Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. Other carriers handle the bill with a global, single-line item charge as long as the claim indicates that an outside facility was used.