Ophthalmology and Optometry Coding Alert

Some Medicare carriers wont pay for both 92020 (gonioscopy) and 92285 (external ocular photography with interpretation and report) performed on the same date of service, but if you work in one of the geographic areas where the local Medicare carrier has such a policy, you may be able to get paid for both. Robert S. Haymond, MD, an ophthalmologist in Angels Camp, CA, needs to do this fairly often, explains his billing administrator Erica Gleason. But he has different reasons for doing each procedure, she says.

The ophthalmologist performs the gonioscopy for glaucoma, and needs the external photos for a lid lesion. He does this often, Gleason explains. Sometimes hell go ahead and do the lesion excision. But still, the photos are necessary to document the condition.

The solution, if your Medicare carrier is bundling these services, says Ramona Cosme, president of Ramco Medical Billing, an ophthalmology billing firm based in Edison, NJ, is the modifier -59but you must go beyond that. The -59 modifier is the one of choice, providing there are separate and distinct diagnoses for each service, she explains. You would put the modifier -59 on the 92020 procedure code, which would have the glaucoma diagnosis code.

Medical Necessity

But its not just enough for you to link the procedure code to a diagnosis code, Cosme cautions. There must be medical necessity as well.

The medical-necessity issue is particularly pressing for the external photos, says Cosme. If Medicare ends up wanting the documentation for this, theyre going to want to know what was seen or what wasnt seen, she says. They also may want to know if the condition is getting better or worse.

In fact, CPT states that 92285 is for documentation of medical progress. This seems to imply that you need some kind of a base line to be documented in terms of lesion size, for example. You are not simply taking a picture for your filesyou need it to keep track of how the condition is progressing.

Modifier -59 is applied to show that a separate procedure was done, representing a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. There is nothing in the definition about the diagnosis being different; however, it is the diagnoses which will result in the justification of breaking the bundle, says Cosme.

Tip: Note that the external photos are payable as a global procedure, or as a technical-only procedure. If you own the equipment, you can bill the global, she says. Most ophthalmologists probably do own their own cameras, so most will probably be using the straight code. If you are billing the professional component only, you would use the modifier -26 on the 92285, says Cosme.

Caveat: The requirements for payment for external photos is very carrier-specific, says Cosme. In order to be paid by any payer for this code, you need an interpretation and report, she explains. But depending on the carrier, you need different specifics to be included.

However, the key is medical necessity, the billing consultant states. If you have the diagnoses to substantiate need, Medicare will most likely pay you, she says. If medical necessity is there, you can unbundle anything, she adds. Thats the purpose of modifier -59. But you cant use it all the time.

And proving medical necessity for external photos can be difficult, Cosme stresses. Theres nothing cut and dried about external photos, she says. If you bill an eye code and gonioscopy, which are bundled, you can get paid if you use a modifier -59 and have medical necessity (e.g., distinct diagnoses that are different for the eye exam code and the gonioscopy). But the external photos may be denied even with what seems like good medical necessity. It doesnt matter whether you use an eye code or an E/M code, says Cosme. If theyre not going to pay for the external photos, theyre not going to pay for them. Most Medicare carriers as well as other payers will have a limited number of diagnostic codes which they think show medical necessity for external photos. Medicare carriers will typically share this information in their bulletins and on their Web sites.

When it comes to billing for external photos which are taken to track a lesion, Cosme urges that you use great caution in looking at medical necessity. Check with your carriers policies. I want to bill optimally, and I want to stay within the confines of HCFA and the carriers, she says. If I stay within the rules, I will usually be paid and protected.

Under what conditions would external photos always be paid? If theres any reconstructive surgery, when you are required to take the pictures in order to get paid for the surgery, responds Cosme. (Oculoplastics is a specialty in which external photos are generally paid.)