Wiki Cataract coding guidelines

[Linda Atherton]

My Ophthalmologists use diagnosis codes: H25.811 and H25.812 instead of the bilateral code. I have not been able to find guidelines that state they have to use the bilateral diagnosis code instead of coding for each eye in the same session. I know ICD-10-CM has guidance for glaucoma coding...can someone direct me to the specific coding guidelines,if there are any? Thank you.

 

[nelliott]

Hi Linda,
It would be under Section 1 Conventions, B. General Coding Guidelines, 13. Laterality. I don't know what brand your ICD-10 book is, but if it's AAPC its on page G5. Hope this helps

 

[TThivierge]

Hi Linda
It seems you used the correct dx code for right and left eye but what procedure was done? CPT 67028 injection and J9035 med? Ensure each line of claim has this CPT code with each Lt or Rt modifier and the corresponding dx code. Also you can use Z01.00 or Z01.01 per documentation provided if annual exam or eye problem noticed. Does the patient have a chronic condition such as Diabetes type 1 or 2 and reason has eye problems.? Check out dx E08.3 , dx E11.351 and dx E10.3 add on the claim if it is underlying condition. I d add it as first dx. Also modifier if related to upper and lower eyelid repairs or treatment? I know if each eye getting a treatment or one eye add that modifier LT or RT and CPT on each line of the claim. do not use modifier 50 for bilateral eye treatments such as injection, or FB removal. Also if pt referred from a family doc add that to the claim too.

Did you know you can go to the CMS website physician services and put in CPT code and give you coding & billing info on it?

Well I hope helped you a little bit.
Lady T

 

[TThivierge]

Hi Linda
Here is the Medicare Physician Fee Schedule look-up tool, which is definitely very useful for reimbursement research. Pop in the CPT code and see dx attached and any more tips

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/

 

[Amelia23]

Are you billing for cataract surgery (66984 or 66982), it is possible that your physicians are still comfortable using the individual codes. Either way both codes being billable you should not have a problem. I've billed the individual codes with an E&M (99202 - 99205; 99212 - 99215) or CEE (92004, 92014) and have not had a problem yet. I try to bill using the guidance of each insurance as they all vary.