Ophthalmology and Optometry Coding Alert

Ophthalmologists and optometrists often work together caring for cataract surgery patients and must use modifiers -54 (Surgical care only) and -55 (Postoperative management only) to bill ethically and in compliance with Medicare.

Medicare expects two co-managing physicians to use these modifiers to break up the global surgery fee on the fee schedule when each physician handles different aspects of the global package. Modifier -54 identifies the work done preoperatively (10 percent of the global package fee) and the intraoperative work, the surgery itself (70 percent of the global package fee). Modifier -55 identifies the postoperative work (20 percent of the global package fee). The physician who performs the surgery also usually performs the preoperative work few surgeons would perform a scheduled operation on a patient they had not examined.

If the surgeon performs the preoperative and intraop-erative portion of the procedure, he or she appends modifier -54 to the surgery code. The service will be approved at 80 percent of the Medicare allowable for the surgery. If the other physician provided all 90 days of the postoperative care, he or she would bill the surgery code with modifier -55 appended and would be paid 20 percent of the Medicare allowable for the surgery.

For example, the optometrist sees a patient for a prescription for eyeglasses, and notices a cataract. The optometrist sends the patient to the ophthalmologist. The ophthalmologist examines the patient and decides that it is medically necessary to perform surgery. The patient is then referred to the optometrist for postoperative care. The ophthalmologist bills 66984-54 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]; surgical care only), and the optometrist bills 66984-55 with 90 placed in the unit field for all 90 days of postoperative if the surgeon did not see the patient during that period.

However, the operating physician as well as the optometrist will use modifier -55. Modifier -55 covers the full 90 days of postoperative care, but the operating physician will see the patient after the surgery, before transferring postoperative care to the optometrist.

Stark anti-kickback rules forbid the operating physician from routinely transferring all patients to another provider on the day following surgery. The surgeon must first determine that the patient is stable and ready to be transferred and how to handle each patient based on his or her status. Some patients might be better off followed by an ophthalmologist than by an optometrist: for example, the patient who gets an anterior chamber hemorrhage the day after surgery.

Under Stark, the ophthalmologist is not allowed to have a standing policy of sending all patients to the optometrist following cataract surgery for the full postoperative care. The Office of the Inspector General has stated that it will prosecute the receiving and transferring provider when an 80/20 split of the global fee always exists.

The surgeon always bills for the surgery with modifier -54. Once the surgeon decides to transfer care, he or she may also bill for some of the postoperative care because he or she has provided at least one day of it.

To calculate how much money the operating physician should charge for a portion of the postoperative care, determine 20 percent of the surgeon's fee for the code. For example, if the surgeon's fee is $1,000, 20 percent for the postoperative care would be $200. Divide that $200 by 90 (for 90 days of postoperative care). That figure, $2.22, is the daily rate for postoperative care.

When filing the claim, the operating surgeon should bill 66984-54 with an $800 fee, and 66984-55 with the number of days of postoperative care indicated in the units field. If the operating physician transferred the patient to the optometrist seven days after the surgery, he or she should put a 7 in the units field on the line for 66984-55. The fee for postoperative care will be $2.22 times 7, or $15.54. The optometrist bills 66984-55 with 83 in the units field, and a charge of $184.26 for 83 days of postoperative care.

Before using modifiers -54 and -55, ophthalmologists and optometrists should consider the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery's recommended guidelines:

1. There must be a justifiable reason for co-management, such as itinerant surgery in a rural area or the patient's inability to travel to the surgeon.

2. No transfer for postoperative care should take place unless it is in the patient's best interest.

3. Co-management must not be done routinely on all patients, but only on selected patients.

4. The surgeon must remain accessible to the patient during the postoperative period at no additional cost. If the patient leaves the optometrist and returns to the surgeon for postoperative care, the two providers must file corrected claims.

5. The ophthalmologist must tell the patient what the financial implications are of co-management with respect to the optometrist's reimbursement and the patient's payment obligations. The AAO also stipulates that the patient should agree to the transfer of care before the transfer is made.