Wiki Second Eye cataract billing

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Stenglein

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The clinic I am working with bills a comprehensive cataract evaluation and decision/orders for surgery for the first eye. During the 90 day global of the first eye, the patient will have a complaint regarding vision, VA will be decreased. The physician determines medical necessity has been met and suggests the second eye surgery with a good prognosis and the patient will agree to the elective procedure. This has been billed as 99213-24. I have read one article stating this is acceptable billing practice (Ophthalmology Management July 2022). At the same time AAO indicates this is incorrect. I tend to agree with the article in Ophthalmology Management. Wondering if anyone has strong thoughts on this.
 
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The global period of a surgery only includes the "pre-operative, intra-operative, and post-operative services routinely performed by the surgeon." Evaluation of a different eye than the one for which the surgery was performed does meet this definition and would not be included in the global surgical package. I'm not sure what the rationale of the AAO is that you're citing, but in my opinion, there's nothing wrong with the use of the modifier 24 for any E&M services that aren't post-operative care for the eye on which the procedure was performed.
 
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As a provider, I have a problem rationalizing the reason for doing things this way. Are you saying that only one eye is examined at the first visit and the decision is made for surgery and that the second eye isn't evaluated until after the first surgery is done and the patient then notes that the VA with the second eye isn't as good as the newly operated eye, as you would expect? If so, IMHO, that's disingenuous and, if audited, would most likely pose some issues regarding the reason for charging a second visit to proceed with the second surgery.

I would tend to agree with the AAO on this matter. During the initial visit, why wouldn't you evaluate both eyes and determine the level of cataract development to determine the eye to be operated on first? In doing the necessary measurements for IOL calculations, why wouldn't you test both eyes? It doesn't really make any sense not to do both at the same time and plan the surgery for both at the same time.

IMHO, unless the surgeons are only evaluating and making the measurements for one eye at the initial examination and then repeating all of that for the second eye when you bill the 99213-24 visit, that just doesn't seem right and would/should raise some flags during audit.

Tom Cheezum, OD, CPC, COPC
 
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I agree with Dr. Cheezum. The AAO gives specific guidance on this subject, and the use of Modifier 24. Both eyes are examined, not one, during the initial E&M. When it's determined that cataracts exist in both eyes, and the patient agrees to have them removed, surgery is planned for both. The first eye is operated on, followed by surgery for the second eye shortly afterward. These procedures have already been decided upon/planned. A diagnostic test is usually performed prior to the surgery on the second eye, which is reimbursable during the global period based on guidelines of what is not included in the global surgical package. When practices get into the practice of billing another E&M and add modifier 24, when there is no "unrelated" problem, this will definitely raise a red flag. Ophthalmology is being looked at closely, as other specialties. The AAO is a great resource for coding guidance/practice management. I work for a huge Ophthalmology practice, and this is something that has been researched and discussed.

Miriam K. Webb, CPC, AAPC Approved Instructor
 
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One other point. Considering the evaluations and measurements which should have taken place during the initial exam prior to surgery, I think you would have a difficult time justifying that the 24 visit was medical necessity, reasonable and appropriate. I work with a very large ophthalmology practice and review charts as I do my job.
The usual CC/HPI I see is something like this: "Patient is seen today with complaint of blurred vision in the left and right eyes" and goes on to detail the HPI aspects. Or something like: "Patient is referred by Dr. X, OD for evaluation for cataract surgery due to blurred vision OU."

I've never seen anything like: "Patient was asked if VA was blurred in OD. No evaluation of visual problems was done for the OS at today's visit." This is what I'd expect to see in your records since the second visit you bill for with the 24 modifier would involve the patient suddenly noticing that the vision in their non operative eye was blurred. As I said, your billing of the 24 visit just doesn't pass the Medically necessary criteria/"smell test."

Tom Cheezum, OD, CPC, COPC
 
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I have reviewed a large number of documents and I can see the rationale for not billing the second eye eval. I am thankful for all your comments!! Wish me well as I present this to a large number of physicians. Thank you!
 
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Stenglein said:
I have reviewed a large number of documents and I can see the rationale for not billing the second eye eval. I am thankful for all your comments!! Wish me well as I present this to a large number of physicians. Thank you!
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Let us know what they have to say, other than they don't want to lose the fee for that 99213-24 visit :)

I work with a group that has about 7 very busy cataract surgeons. If I asked them if they would have the patients come back for the second eye evaluation visit, I know that all of them would say no because they would rather take that time to see a new cataract surgery prospective patient.
Tom Cheezum, OD, CPC, COPC
 
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