Optometry Coding & Billing Alert

Your follow-up service begins the day after the ophthalmic surgeon relinquishes care.

You know that postoperative management of cataract surgery patients is a major component of a typical optometrist's practice -- and, unfortunately, a major headache for optometry billers and coders. The right modifiers, as well as communication with the surgeon's office, go a long way toward clearing up cataract care confusion. The global surgical period for cataract surgeries is 90 days, explains Riva Lee Asbell, ophthalmic coding and reimbursement educator and principal of Riva Lee Asbell Associates in Ft. Lauderdale, Fla. Experts attribute problems reporting cataract care to a misunderstanding of the rules governing postoperative care during the 90-day global surgical period -- especially when the surgeon operates on the second eye within the global period of the first eye.

Scenario: An optometrist refers a 68-year-old Medicare patient with nuclear cataracts (366.16, Nuclear sclerosis) to an ophthalmic surgeon for cataract surgery on her left eye. On June 14, she has the surgery on her left eye. One week later, on June 21, she has cataract surgery on her right eye. On June 22, the ophthalmic surgeon relinquishes care, sending the patient back to the optometrist for the balance of postoperative care on both eyes.

Problem: How does the optometrist code for the follow-up care for both eyes?

Tip 1: Begin Optometrist's Service When Surgeon Relinquishes Care

By the time the optometrist sees the patient, he will be providing a different number of days of postoperative care for each eye. Cataract surgeries, whether reported with 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [1 stage procedure], manual or mechanical technique, complex, requiring devices or techniques not generally used in routine cataract surgery or performed on patients in the amblyogenic developmental stage), 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis [1 stage procedure]) or 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]), have a 90-day global surgical period in which postoperative care may occur.

When an optometrist assumes postoperative care of a cataract patient, his days of service begin the day after the ophthalmic surgeon relinquishes care. In this scenario, the surgery on the left eye occurred on June 14. The ophthalmic surgeon relinquished care on June 22. Thus, for the left eye, the surgeon reports the surgery itself, as well as eight days of postoperative care. The optometrist provides 82 days of care. The postoperative period for the left eye is June 23- September 12, inclusive.

The surgery on the right eye occurred on June 21, the day before the surgeon relinquished care. For the right eye, the surgeon again reports the surgery, but this time only bills for one day of postoperative care. The optometrist provides 89 days of care for the right eye. The postoperative period for the right eye is June 23-September 19, inclusive.

Tip 2: Submit 1 Form per Eye

Keep it simple, say experts -- file your care for each eye on separate CMS-1500 or electronic forms.

Left eye: For date of service June 14, 2010, the surgeon bills 66984-54-LT, appending modifier 54 (Surgical care only) to specify which portion of the global surgical package he is claiming, and modifier LT (Left side) to specify the eye. The surgeon should also bill for eight days of follow-up care with 66984-55-LT (Postoperative management only), with dates of service from June 15, 2010, to June 22, 2010.

On the 1500 form, the optometrist bills for the left eye as follows:

• Line 14 (Date of Current Illness): Leave blank or enter "6-23-10".
• Line 17 (Name of Referring Physician): Enter surgeon's name.
• Line 17a (I.D. Number of Referring Physician): Enter surgeon's UPIN.
• Line 19 (Reserved for Local Use): Write "Assumed post-op care 6-23-10 through 9-12-10" (these days must match the number of days you enter on Line 24g).
• Line 21 (Diagnosis): Enter cataract diagnosis ICD-9 code (e.g., 366.16).
• Line 24a (Dates of Service): Enter "6-23-10" in "From" space. Leave "To" space blank. (Check with your carrier; some prefer you to put the date of the original surgery in this space, instead of the date you assume care.)
• Line 24c (Type of Service): Leave blank.
• Line 24d (Procedures): Enter "66984-55-LT".
• Line 24g (Days): Enter "82".
• Line 24k (Reserved for Local Use): Enter your UPIN.

Watch for: Although you don't have to match the instructions for Line 19 wordfor-word, at least be sure to mention "post-op care," "from," and "to." "The mere presence of a comment in Line 19 kicks the claim out for manual processing," notes David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.

Right eye: For date of service June 21, 2010, the surgeon bills 66984-79-54-RT, appending modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) since this surgery is occurring within the global period of the previous surgery. He also bills for one day of follow-up care with 66984-79-55-RT, for date of service June 22, 2005.

On the 1500 form, the optometrist bills for the right eye as follows:

• Line 14 (Date of Current Illness): Leave blank or enter "6-23-10".
• Line 17 (Name of Referring Physician): Enter surgeon's name.
• Line 17a (I.D. Number of Referring Physician): Enter surgeon's UPIN.
• Line 19 (Reserved for Local Use): Write "Assumed postop care 6-23-10 through 9-19-10" (these days must match the number of days you enter on Line 24g).
• Line 21 (Diagnosis): Enter cataract diagnosis ICD-9 code (e.g., 366.16).
• Line 24a (Dates of Service): Enter "6-23-10" in "From" space. Leave "To" space blank.
• Line 24c (Type of Service): Leave blank.
• Line 24d (Procedures): Enter "66984-79-55-RT".
• Line 24g (Days): Enter "89".
• Line 24k (Reserved for Local Use): Enter your UPIN.
• Tip 3: Check Carriers for Coding Caveats

Do this: To make the claims match up better to Medicare, you should always use the same diagnosis code that the surgeon used to file the surgical claim. A phone call to the surgeon after you see the patient is a great way to remind that office to code properly as well -- and to find out how many days of postoperative care they are filing for.

Caution: Be sure to check with your individual carriers for their coding preferences. Private insurers may have different rules for reporting. Many private insurers do not recognize the postoperative management modifiers, preferring you tobill your services as office visits with eye exam codes (92002-92014) or E/M codes (99201-99215).

Some carriers also want your bills for postoperative comanagement to include the date of the original surgery. For these carriers, you can include this information on line 19, along with the dates of your postoperative care.

Tip 4: See Patient First, Then Bill

Disaster averted: Although the optometrist's days of care start the day after the surgeon relinquished the patient's care, the optometrist cannot bill until he has done the first follow-up visit. So even though your postoperative care starts on June 23, if you don't see the patient until June 30, don't submit a bill until then.

As for the co-management reimbursement, 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. Multiply that by the number of days of post-op care you're providing for your total reimbursement.