Focus on Ophthalmology Coding

From A-scans to YAG.

By Kim Ross, CPC, OCS, and Sue Vicchrilli, COT, OCS

Remember the pirate’s often-lost wooden eye in “Pirates of the Caribbean?” Or Tom Cruises’ eye transplant in “Minority Report?” Movies showing eye injuries intrigue us. Although it is a challenge to code these incidents, an even greater challenge is correctly coding the ophthalmic procedures we see daily. Our focus is to highlight key points in coding the services most frequently performed in ophthalmology.

Evaluation and Management – CEMC

A-scan Ultrasound for Intraocular Lens Calculations

CPT® codes 76519 Ophthalmic biometry by ultrasound echography A-scan; with intraocular lens power calculation and CPT® code 92136 Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation

Report this code for use of the IOL Master, which allow measurements of eye length and surface curvature, necessary for cataract surgery.

Medicare rules differ from non-Medicare payers. For Medicare, these codes have one global technical component (modifier TC Technical component) and a professional component (modifier 26 Professional component) for each eye. Because non-Medicare payers typically do not recognize these modifiers, only the RT Right side or LT Left side modifiers should be appended to 76519 or 92136.

Argon Laser Trabeculoplasty (ALT)

CPT® code 65855 Trabeculoplasty by laser surgery, 1 or more sessions (defined treatment series).

Medicare has assigned a 10-day global period to this code selective laser trabeculoplasty (SLT). This means that when a separately identifiable exam is performed the same day, modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service should be appended to the appropriate level of exam. Because some non-Medicare payers recognize a 90-day global period for 65855, modifier 57 Decision for surgery should be appended to the evaluation and management (E/M) code describing the exam that determines the need for surgery when the laser is performed on the same day. Beginning January 2008, this procedure became payable in an ambulatory surgical center (ASC).

Benign Skin Lesions

Medicare and non-Medicare payers will cover benign skin lesion removal with appropriate documentation. The chief complaint should contain words such as red, increasing in size, oozing, and/or itching. A photo for documentation purposes is helpful. As with any procedure that may be considered cosmetic, it is best to obtain an Advance Beneficiary Notice (ABN) from the patient. Append modifier GA Waiver of liability statement on file to the claim indicating an ABN is on file.

Blepharoplasty

CPT® code 15822 Blepharoplasty, upper eyelid and CPT® code 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid

Most Medicare payers have a Local Coverage Determination (LCD) indicating specific preoperative documentation requirements to distinguish cosmetic vs. functional blepharoplasty. CPT® code 15822 is typically considered cosmetic. By appending modifier GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit, offices indicate as such.

CPT® code 15823 is typically submitted for functional claims. One key component often missing in chart documentation for functional claims is the lack of a visual complaint from the patient. Too often the chart might state, “Patient complains of excessive baggy upper lid skin,” which does not provide medical justification for a functional claim.

Cataract Extraction

CPT® code 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification)

Extracapsular cataract removal is the number one procedure performed in ASCs. Contrary to what many physicians and coders think, there isn’t a national policy with a visual acuity requirement. Coverage varies by payer. The best documentation indicates the impact the reduced vision has on the patient’s daily living activities.

Complex Cataract Extraction

CPT® code 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage

It’s important to note that this CPT® code is not for:

  • Complications that occur during surgery
  • Vitrectomy performed at the time of surgery
  • Piggyback or multi-focal IOLs
  • Specific viscoelastic like Healon 5 or Healon GV
  •  Complex cases that take longer than usual
  • Diagnosis of floppy iris syndrome or use of Sugarcaine intraoperatively
  • Extraordinary services performed in routine cataract surgery

Note: Payers who have coverage policies also allow coverage for mature white cataract requiring dye for capsulorrhexis, which is the making of a continuous circular tear in the anterior capsule during cataract surgery to allow evacuation by pressure of the nucleus of the lens.

Fluorescein Angiography

CPT® code 92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report

This test has unilateral payment, which means 100 percent of the allowable fee is payable per eye when medically indicated. It is inappropriate to submit a claim for the eye that does not have pathology. Claims may be submitted as a single line item (eg, 92235-50) or a two-line item with the RT and LT modifiers (eg, 92235-RT, 92235-LT), depending on payer preference. Cost of the dye is not separately payable.

Fundus Photography

CPT® code 92250 Fundus photography with interpretation and report

This code is inherently bilateral. Payment is the same whether one or both eyes are photographed. The National Correct Coding Initiative (NCCI) bundles fundus photography with CPT® code 92135 Scanning computerized ophthalmic diagnostic imaging, posterior segment, (eg, scanning laser) with interpretation and report, unilateral

Foreign Body

CPT® code 65222 Removal of foreign body, external eye; corneal, with slit lamp

This code has a zero-day global period, which means when the physician sees the patient a few days later, it is a billable exam. The procedure is payable per eye, not per foreign body. And in the event a rust ring develops, 65222 is the appropriate code to use again.

Keratoplasty

The following new procedures have already received ASC approval:

65710      Keratoplasty (corneal transplant); anterior lamellar

65730      Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)

65750     Keratoplasty (corneal transplant); penetrating (in aphakia)

65755   Keratoplasty (corneal transplant); penetrating (in pseudophakia)

65756  Keratoplasty (corneal transplant); endothelial

+65757  Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure)

Lacrimal Punctal Plugs

CPT® code 68761 Closure of the lacrimal punctum; by plug, each

This is the only lacrimal procedure where payment is per puncta, not per eye. The code is the same whether using temporary (collagen) or permanent (silicone) plugs. Typically, it is not necessary to distinguish the difference to the payer. In 2002, Medicare bundled the supply of the plug(s) with the insertion. Non-Medicare payers may pay separately for the supply of the plug with HCPCS Level II codes A4262 Temporary, absorbable lacrimal duct implant, each for collagen, A4263 Permanent, long term, non-dissolvable lacrimal duct implant, each for silicone, or CPT® code 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (List drugs, trays, supplies, or materials provided).

Patient complaint should document dryness, burning, itching, excessive tears, and/or photophobia. Documentation should indicate other methods of treatment have been tried and proven unsuccessful before plug insertion. This could include artificial tears, ointments, humidifier, etc.

Optic Nerve Scan

CPT® code 92135 Scanning computerized ophthalmic diagnostic imaging, posterior segment, (eg, scanning laser) with interpretation and report, unilateral

In 2006, this service was billed more than five million times to Medicare. One hundred percent of the allowable is paid per eye when medical necessity exists. Contact your intermediary to confirm medical necessity.

Ophthalmoscopy

CPT® codes 92225 Ophthalmoscopy, extended with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial and 92226 Ophthalmoscopy, extended with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent

As with other procedures that have unilateral payment, 100 percent of the allowable is paid per eye when medical necessity exists. Payment is for the detailed drawing, not for viewing. The drawing should be detailed, but payers no longer require a colored drawing.

Pachymetry

CPT® code 76514 Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

Payment for 76514 is the same whether testing one or both eyes. This procedure is covered by Medicare as a one-time basis for glaucoma usually, but also as indicated in the progression of corneal disease.

Pterygium

CPT® codes 65420 Excision or transposition of pterygium; without graft and 65426 Excision or transposition of pterygium; with graft

No matter the source of the graft, it is bundled with the surgical code (65426). Amniotic membrane transplant is not separately billable per CCI.

Suture Removal

CPT® codes 15850 Removal of sutures under anesthesia (other than local), same surgeon and 15851 Removal of sutures under anesthesia (other than local), other surgeon.

Aside from these two codes, suture removal is never separately payable. It is part of the global surgical fee or any E/M or eye code billed if you were not the surgeon or if the patient is out of the global period. Never report suture removal as a corneal foreign body. Laser suture lysis is considered suture removal. It is inappropriate to code 66250 Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure for this service.

Topography

CPT® code 92025 Computerized corneal topography, unilateral or bilateral, with interpretation and report

This was a new code in 2007. Payment is the same whether one or both eyes are tested. Do not report 92025 with any corneal transplant code after the decision for surgery has been made, and until the end of the global period. This helps to maintain the value of the surgical code.

Visual Fields

CPT® code 92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent), 92082 Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33), and 92083 Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).

Payment for these codes is the same whether one or both eyes are tested. CPT® code 92081 or 92082 is appropriate for documentation prior to blepharoplasty.

YAG Laser Capsulotomy

CPT® code 66821 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages)

Typical LCD indicates documentation should reflect:

  • Vision loss due to decreased light transmission (visual acuity of 20/30 or worse after other acuity loss causes have been ruled out).
  • Increased glare. Test results must show decrease in two lines of visual acuity in glare tester.
  • Indication of the impact the reduced vision has on the patient’s daily activities.

Medicare payers do not expect to see this procedure performed regularly within the cataract global period, and may request documentation.

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2 Responses to “Focus on Ophthalmology Coding”

  1. Barbara Idler says:

    I would like to get certification training in opthamology

  2. Ophthalmology Information says:

    Hi,

    Thanks for this post!!

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