Skipping these -26 and -TC rules could be costing you $86 per patient
Calculating IOL strength for patients facing cataract extraction is a straightforward part of most optometrists' workloads - but the rules for coding and billing these procedures are far from simple. Our experts show you how to make sure you get your fair share of the more than $470,000 that Medicare pays optometrists yearly for these procedures.
When a patient is facing cataract extraction with intraocular lens implant (IOL) insertion, an optometrist must often perform either an A-scan or an IOL Master measurement to determine the type and power the IOL should be.
Medicare divides these procedures into technical and professional components, and has set rules about which components you can - and cannot - report bilaterally. And if you're sharing the work with an ophthalmologist, your coding task is all the more complex.
Include Both Eyes in -TC
The IOL Master (92136, Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation), or optical coherence biometry (OCB), is becoming the gold standard for IOL measurements. OCB is a more advanced way of calculating IOL power than the A-scan (76519, Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation).
The expense of the IOL Master prevents many private-practice optometrists from using it, but ODs in larger eye practices who have access to the technology generally prefer it to the A-scan. (Since the code debuted in CPT 2002, optometrists have billed 92136 to Medicare over 590,000 times, according to CMS statistics.) However, there are cases (such as mature cataracts) that require ultrasound echography instead of OCB, says Jennifer Young, CPC, administrator for the Singer Eye Center in Randolph, Vt.
Key: Medicare divides both 76519 and 92136 into two components - the technical component, marked by appending modifier -TC (Technical component), and the professional component, which you indicate with modifier -26 (Professional component).
Medicare's Physician Fee Schedule Relative Value file assigns CPT codes modifier indicators that determine how Medicare reimburses codes that are reported bilaterally.
Snag: The professional component of the IOL Master has a different bilateral status than the technical component, Young says. The same is true for the components of the A-scan procedure.
The technical components of both 76519 and 92136 are marked with modifier indicator "2," which means that Medicare considers the codes inherently bilateral.
The work for performing the technical component of the procedures on both eyes is included in the single CPT codes - you should report 76519-TC or 92136-TC only once, whether you examine one or both eyes.
Optometrists typically perform the technical component of the procedures (the actual measurement of the eye) on both eyes at the same time, Young says.
Consider -26 Inherently Unilateral
However, the professional components (76519-26 and 92136-26) are marked with modifier indicator "3," which means that the codes are inherently unilateral.
Even though you perform the technical component on both eyes, you (or the ophthalmologist whom you're working with) may calculate the IOL power only for the eye that will receive the IOL. One unit of 76519 or 92136 without modifiers, therefore, includes:
Double RVUs for IOL Calculations in Both Eyes
For most carriers, if you calculate the IOL power in both eyes, you would need to bill on two lines, reporting the technical and professional components like this, Benson says:
Line 1: 76519-26-50 or 92136-26-50
Line 2: 76519-TC or 92136-TC.
Appending modifier -50 (Bilateral service) to the professional component of these procedures should double your reimbursement. The fee schedule values the professional components of both 76519 and 92136 identically, at 0.79 relative value units (RVU). Reporting either code bilaterally should yield 1.58 RVUs, which, multiplied by the conversion factor (37.8975) yields $59.88 (unadjusted for geography). Adding that to the technical component RVUs (1.38 for 76519 or 1.48 for 92136) brings your total to $112.18 for 76519 or $115.97 for 92136.
Use Modifiers to Split Work With Surgeon
If, however, you perform the technical component 76519 or 92136 on both eyes, and the ophthalmologist interprets the test and calculates the IOL power for one:
