Ophthalmology and Optometry Coding Alert

Question: We have a Medicare patient who will be having a levator resection on his right eye for ptosis. The ophthalmologist wants to do this as a bilateral procedure, but the patient's left eye is a non-seeing eye. Since the operation on the right side may be medically necessary, but the left side would likely be considered cosmetic, how should I code this surgery?Wisconsin SubscriberAnswer: Report each side of the bilateral procedure on a separate line, appending modifiers LT (Left side) and RT (Right side), linking each side to the appropriate diagnosis code explaining the necessity for the surgery.In this case, one side will be medically necessary, while the other will be cosmetic -- the procedure will not benefit the vision on the non-seeing eye.Do this: Have the patient sign an advance beneficiary notice (ABN) prior to the surgery, stating that he is aware that Medicare may not cover the [...]