Ophthalmology and Optometry Coding Alert

Know Medicare's rules on modifiers to get fair payment for co-managed care

Ophthalmologists and optometrists often work together caring for cataract surgery patients and must use modifiers -54 (Surgical care only) and -55 (Postoperative management only) to bill ethically and in compliance with Medicare.

Medicare's Physician Fee Schedule Database divides the percentage of relative value units into the procedure's pre-, intra- and postoperative components. Modifier -54 identifies the work done preoperatively and the intraoperative work, the surgery itself. Modifier -55 identifies the postoperative work.

The physician who performs the surgery also usually performs the preoperative work -- few surgeons would perform a scheduled operation on a patient they had not examined.

Use Modifiers to Divide the Code

If the surgeon performs the preoperative and intraoperative portion of the procedure, he appends modifier -54 to the surgery code. If the other physician provided all 90 days of the postoperative care, he would bill the surgery code with modifier -55 appended.

Example: An ophthalmologist performs cataract surgery and refers the patient to an optometrist for postoperative care. The ophthalmologist bills 66984-54 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]; surgical care only), and the optometrist bills 66984-55 with 90 placed in the unit field for all 90 days of postoperative if the surgeon did not see the patient during that period, says Vanessa A. Joy, CPC, with University Eye Surgeons in Knoxville, Tenn.

The optometrist should only report an E/M code for his co-management service in the rare case that he treats another problem, unrelated to the original surgery. If this were the case, he would append modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M code.

Split Costs 80/20

As for the co-management reimbursement, Medicare considers the 90-day period following cataract surgery reimbursable at 20 percent of the overall procedure charge (the pre- and intraoperative work making up the other 80 percent of the reimbursed payment).

To avoid problems with claim denials, it is important to coordinate the billing of co-management claims between the optometrist and the ophthalmologist. Submit each claim with the same CPT code -- with the correct modifier to identify surgical care or post-op care -- and the same diagnosis code. Also, make sure the optometrist's office knows how many days of postoperative care you plan to file for. They can then subtract that total from 90 and file for the balance of the postoperative days.

Example: A surgeon sees the patient on the 23rd day after postoperative care and refers the patient to an optometrist for the balance of the postoperative days. The optometrist doesn't see the patient until the 35th day after the surgery. The surgeon may bill for 34 days of postoperative care. The optometrist should not bill for days before he actually sees the patient, so he should bill for 56 postoperative days.