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Ophthalmology and Optometry Coding Alert

You Be the Coder:

Split the Bill (Correctly) With Modifier -55

Published on Fri Aug 01, 2003

Question: We have a single ophthalmologist in our practice who relies on optometrists from time to time to provide post-op care for cataract patients. Our doctor always checks in on the patient after surgery to make sure they're stable, but we haven't been billing for the visit. In these cases, we have been using the 80/20 split because we transfer care to the OD, but we hear that we might not be handling this correctly. How should we split the payment on such co-managed patients?

Texas Subscriber

Answer: The reaction you're hearing over your use of the 80-20 split probably has to do with the Stark anti-kickback rules. The rules prohibit the standard practice of assigning all cataract post-op treatment to optometrists. If you always do this, you run the risk of the Office of Inspector General (OIG) checking into this and possibly prosecuting you and the receiving optometrist.

Although the way your practice is handling this situation isn't motivated by an under-the-table kickback agreement, your current coding practice could put your office at risk.

You should be accurately splitting the post-op care charge between your physician and the optometrist. As you know, Medicare considers the 90-day period following cataract surgery reimbursable at 20 percent of the overall procedure charge (the pre- and intraoperative work making up the other 80 percent of the reimbursed payment).

To figure the split, you first calculate 20 percent of the overall charge for the service. Then, divide that total by 90. This gives you the per-day value of the post-op management service.

 If you have provided cataract surgery for a patient and will co-manage her postoperative care with an optometrist, you will want to do the following:

1. Code for the surgical procedure, adding modifier -54 (Surgical care only). This covers the pre- and intraoperative portions of the surgery.

2. You also will code for the post-op care delivered by your ophthalmologist, using the initial surgical code plus modifier -55 (Postoperative management only).

3. In the units field, you should put in the number of days of service your physician provides, which calculated out like above will yield the total charge for the service.

The charge may be small, but accurate coding of this service will payoff big as you avoid OIG scrutiny.

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