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 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 (ABN) prior to the surgery, stating that he is aware that Medicare may not cover the entire procedure. Append modifier GA (Waiver of liability statement on file) to the procedure done on the non-seeing eye to indicate that the patient knows he is responsible for the 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 claim, and the explanation of benefits (EOB) will confirm that the patient is responsible for the rest.

Note: For more information on proving medical necessity for blepharoptosis repair, see "Determine Surgical Approach, Technique to Hit Blepharoptosis Repair Coding Bull's-Eye" in the September 2005 Ophthalmology Coding Alert.