Ophthalmology and Optometry Coding Alert

Some ophthalmologists perform A-scans (76519) on the same day as cataract surgery (66830-66984). They also want to bill the office visit for the same day. This is basically one-stop shopping, which is convenient for the patient, but getting paid for the office visit may be difficult. Ophthalmologists can bill for all three with modifier -57 (decision for surgery), but your documentation must support this. Its very unusual to have to do a new exam with cataract surgery in one day.

Cataract surgery is usually elective, explains Ramona Cosme, president of Ramco Medical Billing Inc., an ophthalmology coding, reimbursement and compliance consulting firm based in Edison, N.J. To do the office visit, A-scan and surgery on the same day, there would have to be something traumatic to the eye to justify medical necessity. Normally, notes Cosme, a physician performs a consultation, determines there is a cataract, determines what kind of cataract it is, and then schedules surgery. Theres a procedure, and it should be followed, she says. Theres a do it now case, and theres a do it later case. Most cases of cataract surgery are do it later, she says.

When billing the office visit, A-scan, and surgery on the same day, the modifier -57 should be appended to the office visit.

Tip: Make sure you put the -LT or -RT modifier on the cataract surgery code.

Emergency vs. Elective Surgery and Modifier -57

The -57 modifier is to be used when the physicians initial determination that the patient needed major surgery (a procedure with a 90-day global period) was made on that day and the procedure is performed that day or the next day. If the physician had already determined the need for surgery in a previous visit and chooses to see the patient the day before or the day of the surgery, that visit is considered preoperative and is not separately billable. The global surgical package for major surgeries includes preoperative visits that occur the day before or day of surgery. Usually, a decision to do surgery is made at least one week prior to doing the surgery, which enables getting the case scheduled into an operating room (hospital or ambulatory surgical center).

Traumatic cataracts that do not involve other trauma to the eye (e.g., retinal detachment) are not usually emergency cases, explains Lise Roberts, vice president of Health Care Compliance Strategies, a coding, compliance and reimbursement consulting firm based in Jericho, N.Y. Traumatic cataracts typically develop either very rapidly or slowly after the trauma, but even in the rapid development cases there is no immediate threat to permanent loss of the use of vision if the cataract is not taken out.

Retinal detachment repair (67101-67112), however, is a good [...]