Optometry Coding & Billing Alert

Question: After we had done an A-scan on a patient prior to cataract surgery on his left eye, he returned a month later for an A-scan on his right eye. We reported 76519-26 and 92012-26, using modifier 26 to show that this service was for calculating IOL power of the second eye. Medicare paid 76519-26 at a very reduced rate and didn't pay for 92012-26 at all. Is there a better way of coding this?

Mississippi Subscriber

Answer: You will probably never see payment for 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) in this case. Medicare considers that if the second eye is done in the global period of the first eye, the initial determination to do the second eye was made at the same time as the first eye determination.

Medicare denies the examination for the second eye because they see it as the preoperative examination portion of the global package.

Warning: You should also never append modifier 26 (Professional component) -- which is for the professional or physician component (as opposed to the technical [modifier TC] or ultrasound component) -- to 92012. The eye exam cannot be split into professional and technical components.

For the ultrasound, however, modifier 26 is appropriate. That's because 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) has a technical and a professional component.

When you performed the A-scan on the first eye, you could bill the global 76519 for both the technical and the professional components. For the second eye calculation done within a year of the measurements, however, the technical portion -- the A-scan -- was already performed. You would only bill for the professional component.

Billing 76519-26 would indeed reduce your fee because you are being paid only for the professional service of determining the power and style of IOL implant.

Tip: Try attaching the side modifiers, RT (Right side) and LT (Left side), to the A-scan codes so Medicare understands that the second eye is the one you are billing for.