Ophthalmology and Optometry Coding Alert

Question: A patient came in for a GDX and visual field (VF) tests. During the same visit, the ophthalmologist put in temporary plugs. Can we get paid for all services on the same day?

Florida Subscriber

Answer: Provided the ophthalmologist made the decision to perform the tests during this visit, you may bill for the office visit and the testing. You should be able to get paid for all services using four modifiers -- one on the office visit as you indicated, one on each plug code, and one on the GDX. You do not need a modifier on the VF (92081-92083, Visual field examination, unilateral or bilateral, with interpretation and report ...).

Warning: If the patient was scheduled to come in for the GDX and VF testing as the result of a previous office visit, you should bill only the GDX and VF testing.

Unless there is a need for the physician to perform another office visit evaluation (worsening symptoms, new symptoms), do not report the office visit. Inserting a plug (68761, Closure of the lacrimal punctum; by plug, each) is a minor procedure that includes related evaluation and management work. You should only report an E/M when documentation supports the service as significant and separately identifiable from the plug insertion. In these cases, you need modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the office visit (99201-99215, Office or Other Outpatient Services).

Make sure to use separate diagnoses for the problem and for the primary reason or diagnosis for the visit.

Money-saver: Code 68761 is per plug. Therefore, use the insurer's preferred method of designating eye location. Indicate the affected the lacrimal punctums closed with the appropriate body-side modifiers (LT, Left side; and/or RT, Right side) or E modifiers (such as E1, Upper left, eyelid). Although Medicare carriers require the E modifiers, most private payers want RT and/or LT.

On the GDX (92135, Scanning computerized ophthalmic diagnostic imaging, [e.g., scanning laser] with interpretation and report, unilateral), use the appropriate body-side modifier: LT or RT. So if the patient had the GDX on the left eye and the upper punctums of each eye closed, the services for an insurer not recognizing E modifies could include:

• modifier 25 on 99201-99215 for the office visit

• 68761 listed twice, once with modifier RT and once with modifier LT for the two plug placements

• modifier RT or LT on 92135 for the GDX

• no modifier on 92801-92803 for the VF.