Keep an Eye on Diagnostic Ophthalmology Updates
Overlooking 2017 CPT® changes will keep your procedural reporting in the dark ages.
Correct diagnostic ophthalmology coding is important to patients, the coders and billers who process the claims, and the physicians who document the medical records. Review these important guidelines to ensure you understand common diagnostic tests performed by this specialty.
Fluorescein and Indocyanine Green Angiography
CPT® 2017 brought changes to the code descriptors for 92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral and 92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral. Both codes now identify “unilateral or bilateral” services — making bilateral modifier and unit reporting unnecessary, unless the payer specifically requests this information. In the Medicare Physician Fee Schedule Database (MPFSDB), the bilateral indicator has changed from “3” to “2,” indicating that there is no longer a 100 percent payment for each side when the procedures are performed bilaterally.
Submitting 92235 and 92240 for the same session is considered unbundling, and is not appropriate. Instead, CPT® 92242 Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral reports fluorescein and indocyanine green angiography performed at the same encounter.
In both fluorescein and indocyanine green angiography procedures, a dye is injected into the patient’s vein. When the dye reaches the retina and is exposed to a specific light wavelength, the areas it enters can be seen. Photographs are taken of the blood vessels in the fundus to inspect the structure and identify leaks. The main difference between the procedures is the type of dye used; indocyanine green dye is preferred for certain retinal diseases. These procedures are considered valuable diagnostic tools in patients with diabetic retinopathy, retinal and macular disorders, and certain ocular tumors and optic disc diseases.
Ophthalmic A-scan and
Optical Coherence Biometry
In ophthalmic A-scan biometry (CPT® code 76519 Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation), the axial length of the eye is measured by ultrasound prior to cataract surgery to determine the intraocular lens (IOL) calculation. Optical coherence biometry (OCB) (CPT® 92136 Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) is an alternate method for measuring the eye using laser technology. This is a newer technique generally considered to be more accurate than the ultrasound procedure.
Both codes are similar in one specific way: The professional component of the codes is a unilateral procedure, but the technical component is a bilateral procedure. Often, when a patient has bilateral cataracts, the surgeries are performed several weeks apart. In this case, the technical portion of the procedure is performed bilaterally, one time, and the IOL power is calculated for the eye to be operated on prior to each procedure.
As an example, prior to cataract surgery on the right eye, the technical portion of 92136 is performed on both eyes, and the professional component (calculation of the IOL power) is performed on the right eye. Later, prior to the left eye cataract removal, the professional component is performed for the left eye.
Although payers’ reporting regulations differ, keep in mind that the professional service is billed only for the eye for which an IOL power is computed. As shown in Tables 1 and 2, Palmetto GBA requires modifier 26 Professional component or modifier TC Technical component to be submitted in the first modifier field, when applicable. This carrier specifically does not use modifiers RT Right side and LT Left side to identify laterality; however, it does require appending modifier 52 Reduced services to indicate that an otherwise bilateral code is performed on only one eye. Other carriers may require use of modifiers RT and LT: Check your payer’s policy carefully.
|Ophthalmic Biometry A-scan with IOL Power Calculation 2|
|Components Performed||CPT® Code||HCPCS/CPT® Modifier||Days/Units (Quantity)|
|Bilateral TC and unilateral PC||76519||None||1|
|Bilateral TC component||76519||TC||1|
|Unilateral TC component||76519||TC, 52||1|
|Unilateral TC component and unilateral PC||76519||52||1|
TC = Technical Component PC = Professional Component
|Ophthalmic Biometry 2|
|Components Performed||CPT® Code||HCPCS /CPT® Modifier||Days/Units (Quantity)|
|Bilateral TC component and unilateral PC||92136||NONE||1|
|Bilateral TC component||92136||TC||1|
|Unilateral TC component||92136||TC, 52||1|
|Unilateral TC component and unilateral PC||92136||52||1|
TC = Technical Component PC = Professional Component
In 2016 and previous years, the MPFSDB listed the professional component as unilateral; the initial 2017 MPFSDB wrongly lists the professional component as bilateral. The Centers for Medicare & Medicaid Services (CMS) is correcting this and is changing the bilateral surgery indicator of “2” for the professional component back to “3” (identifying that the procedure may be paid at 100 percent of the fee schedule for each side) with the April 1, 2017 MPFSDB update. After April 3, 2017, providers may request adjustments on previously processed claims.
Routine ophthalmoscopy, which allows the provider to see inside the fundus of the eye, is bundled into an eye exam or evaluation and management (E/M) code. Extended ophthalmoscopy (EO) goes beyond that of routine ophthalmological services. In this procedure, the provider typically uses an indirect ophthalmoscope with a bright headlight and a handheld lens. Medically necessary diagnoses include retinal diseases such as tears, detachments, hemorrhages and tumors, proliferative retinopathy, and glaucoma.
A common confusion in coding is differentiating 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. Code 92225 is used appropriately for the initial EO for new symptoms and 92226 is used for subsequent EOs for the same symptoms or diagnosis.
For example, a patient presents to the ophthalmologist’s office complaining of flashes and floaters in his left eye. The physician performs an initial EO on the left eye and identifies a horseshoe retinal tear. This is coded using 92225-LT and the appropriate retinal tear code.
The same patient returns six weeks later, complaining of seeing new flashes and a spider web design in his right eye. The physician performs an EO for this initial problem and reports 92225-RT, this time linking it with the newly-assigned diagnosis.
If the patient is seen again for re-evaluation of his current problems on either eye, the subsequent evaluation of an existing problem is reported using 92226 with the appropriate modifier LT or RT appended. Whether the patient is new or established to the practice has no bearing on code assignment.
Documentation requirements for these procedures vary by carrier, but generally include:
- Retinal drawings meeting the carrier’s size, color, and detail guidelines in which all items are clearly identified and labeled
- Additional documentation for a diagnosis of glaucoma (which includes a separate detailed drawing of the optic nerve, identifying any cupping, disc rim, pallor, and slope and surrounding pathology)
- Medical necessity for each eye examined
- Documentation that the pupil was dilated and what drug was used
- The method or instruments used for evaluation
- All findings and a plan of action
There are multiple local coverage determinations and commercial carrier guidelines for these codes, so you must ensure the medical record is compliant. Frequently, these procedures are not appropriately documented due to overreliance on electronic health records (EHRs). The detailed drawings that Medicare and other carriers require are difficult to process through many EHRs. If this is the case, consider manually documenting and scanning the drawing into the medical record.
Both EO procedures are considered unilateral and are reimbursed at 100 percent for each eye, when medically necessary. If the procedure is performed within the global period of an unrelated eye surgery, it may be necessary to append modifier 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.
How Ophthalmic Disease Affects the Patient Population
Cataracts affect more than 24.4 million Americans age 40 and older, and nearly half of individuals by age 75. Diabetic retinopathy affects nearly 7.7 million people age 40 and older and glaucoma affects more than 2.7 million in the same age range. Nearly 2.1 million Americans over 50 have late age-related macular degeneration (AMD); and, by age 80, one in 10 Americans has late AMD (see www.aao.org/newsroom/eye-health-statistics#impairmentandblindness).
Palmetto GBA, Ophthalmic Biometry and A-Scans Coding Guidelines:
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April CY 2017 Update: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9977.pdf