Ophthalmology and Optometry Coding Alert

Avert new code confusion

Code 76514 has replaced Category III code 0025T in 2004 for pachymetry - and not only has the code changed, but the description has changed as well.
 
The previous description of the service included the language "with interpretation and report"; a clear indication to physicians that they needed to document the professional portion of the service, the interpretation. The new code and description do not indicate that interpretation and report are required.
 
For 76514, (Ophthalmic ultrasound, echography, diagnostic; corneal pachymetry, unilateral or bilateral [determination of corneal thickness]), Medicare fee schedule values the service with a technical component and professional component, which means to accurately bill for the entire service, you must document both components. The AMA's decision to convert 0025T from a Category III code to a Category I code reflects the usefulness and popularity of the procedure.

Fight for Your Right to Pachymetry

Currently, most carriers will not reimburse providers for pachymetry if their patient has a previous diagnosis
of glaucoma.
 
In many areas, ophthalmologists continue to challenge this exclusion - and some have successfully convinced carriers to cover pachymetry for their glaucoma patients. "It's essential to one portion of the eye exam," says Christine Fitzgerald, CPC, office manager at the Rhode Island Eye Institute.
 
"We basically have been doing these things for free because our carrier in Rhode Island doesn't cover it.
 
We're hoping that with the new categorization of the code that it's going to be a covered benefit. Neighboring Massachusetts Medicare is paying for it under the 0025T," Fitzgerald argues, "so we tried to use that ammunition with our Rhode Island carrier.
 
"When we we first bought the pachymetry machine, we were appealing everything. But we're talking about a $20 test, and we were spending $50 in administrative work to appeal it.
 
"We pretty much gave up on it," Fitzgerald says. "We are hoping now with the new 76514 we'll have a little better luck."