Ophthalmology and Optometry Coding Alert

Question: We have a Medicare patient who will be having a leva to 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 Subscriber

Answer: 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 of non-coverage (ABN) prior to the surgery, stating that he is aware that Medicare will not cover the procedure performed on the left eye. Be sure your ABN is in layman's terms and specifies the specific reasons for non-coverage. (Do not use CPT/ICD9 codes on the ABN form). You must also specify the estimated cost of the service on the ABN. The original signed ABN indicating the patients decision (be sure the patient has selected one of the options) to accept financial responsibility, is maintained by the practice and a fully executed copy must be provided to the patient. Append modifier GA (Waiver of liability statement on file) to the procedure done on the non-seeing eye to indicate that the patient was informed in advance and has selected the option to be responsible for the non-covered service and unpaid amount.

Example: The patient has congenital ptosis (743.61), and his left eye is non-seeing. The ophthalmologist performs levator resection (67904, Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) bilaterally. Code as follows:

• Line 1: 67904-RT linked to 743.61
• Line 2: 67904-LT-GA linked to V50.1 (Elective surgery for purposes other than remedying health states; other plastic surgery for unacceptable cosmetic appearance).

If your documentation shows that the procedure was medically necessary on the right side, Medicare will reimburse the full amount for 67904-RT. The cosmetic diagnosis linked to 67904-LT-GA will prompt the carrier to deny the specific service due to the diagnosis and noncoverage of cosmetic services, and the explanation of benefits (EOB) received by the patient will confirm that the patient is responsible for payment.