Ophthalmology and Optometry Coding Alert

Tricky technical and professional components could cost you $86 per patient

When your ophthalmologist plans to perform cataract extraction with intraocular lens implant (IOL) insertion, he must perform either an A-scan or an IOL Master measurement to determine the type and power the IOL should be. But some clinical circumstances might require him to do both tests on one patient - and an National Correct Coding Initiative bundle presents a coding conundrum.

Our experts show you how to steer clear of payer problems when reporting these pre-IOL insertion services by heeding the NCCI edits while still maximizing your reimbursement. Master the Rules for -TC and -26 Partial coherence interferometry (92136, Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) done with an IOL Master device is a more advanced way of calculating IOL power than the A-scan (76519, Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation). Ophthalmologists who have an IOL Master generally prefer it to the A-scan for IOL measurements.

However, there are cases (such as mature cataracts) that require ultrasound echography. For some patients, an ophthalmologist might even have to perform both tests - if he can't get a viable result in one eye from the IOL Master, he would do an A-scan in that eye instead.

Both 76519 and 92136 are divided into two components - the technical component, marked by appending modifier -TC (Technical component), and the professional component, which you indicate with modifier -26 (Professional component).

The Medicare National Physician Fee Schedule Relative Value file assigns CPT codes modifier indicators that determine how Medicare reimburses codes that are reported bilaterally.

Experts warn: The technical component of both 76519 and 92136 is marked with modifier indicator "2," which means that the codes are considered inherently bilateral.

The work for performing the procedure on both eyes is included in the single CPT codes - you should report 76519-TC or 92136-TC only once, whether one or both eyes are examined.

The professional components (76519-26 and 92136-26) are marked with modifier indicator "3," however, which means that the codes are inherently unilateral, says Elizabeth Borgen, billing specialist for the North Dakota Eye Clinic and Surgery Center in Grand Forks. This is because the technical component of the procedure - the actual measurement of the eye - is typically performed on both eyes at the same day, she says. The ophthalmologist may, however, only perform the professional component - the IOL power calculation - on the eye that he's going to operate on.

Billing one unit of 76519 or 92136, therefore, includes:
   the technical work involved in measuring both eyes, and
   the professional work involved in IOL power calculation for one eye. Watch for Doctors Doing Both Tests at [...]