Ophthalmology and Optometry Coding Alert

Question: One of our doctors has started performing the corneal limbal relaxing procedure for elective purposes. What CPT code should we use to report this procedure?

New Hampshire Subscriber

Answer: You should report elective corneal limbal relaxation procedures using 66999-GY (Unlisted procedure, anterior segment of eye; Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non- Medicare insurers, is not a contract benefit).

Caution: You may think 65772 (Corneal relaxing incision for correction of surgically induced astigmatism) sounds like an appropriate code to use for this procedure. But this code only applies to surgically induced astigmatism.

If the astigmatism is not surgically induced, the procedure is generally a noncovered elective refractive surgery. So if the ophthalmologist wants to correct pre-existing astigmatism at the same time he removes cataracts by doing the corneal limbal relaxation along with the cataract surgery, for example, you should inform the patient that Medicare considers the procedure non-covered.

Tip: When you append modifier GY to 66999, you're telling Medicare that although the service is not covered, you're submitting the claim to obtain a denial to submit to the patient's secondary insurance or that the patient specifically requested you to submit the claim.

Pitfall: You are not required to obtain an advance beneficiary notice of non-coverage (ABN) for a service that Medicare deems a noncovered service. Therefore, you would append modifier GY and/or GX to the service. The patient is always responsible for payment of a procedure that is never covered. Starting April 1, 2010, when your practice issues a voluntary ABN for a particular service, you'll turn to modifier GX.

CMS defines modifier GX as "notice of liability issued, voluntary under payer policy." You will use modifier GX when you need a denial remittance advice to submit for secondary insurance, when Medicare does not pay as primary, but the secondary insurance does pay with a denial explanation of benefits (EOB).

Old way: Before CMS revised the ABN last year, you would have used a Notice of Exclusion of Medicare Benefits (NEMB) form for these cases. CMS eliminated the NEMB, however, so modifier GX helps you tell the payer you have a voluntary ABN on file. You might also use the ABN for a never covered service if a patient does not believe the service is not covered and insists that you submit the claim to Medicare.

You would have the patient sign the ABN and submit the service to Medicare with a GX modifier so that the patient receives the denial remittance advice. For more information on modifier GX, visit www.cms.gov/MLNMattersArticles/downloads/MM6563.pdf.