Ophthalmology and Optometry Coding Alert

Coding for the 90 days following cataract surgery can be tricky. Thats because there are frequently other problems which arise during that period. How can you get paid for handling them, when the fee for the surgery is global?

1. Exam of second eye: Modifier -24 and -LT/-RT.
Lets say the surgery was done on the left eye. But a few weeks later, you need to examine the right eye. How can you get paid for that office visit? The answer is to use modifier -24 and the -LT or -RT modifiers to indicate which eye the service is for, our experts say.

First of all, the -24 modifier is for services provided during the post-op period which are unrelated to the surgery. The -24 modifier is for an unrelated evaluation and management service by the same physician during a postoperative period (CPT 1999).

If the surgery was done on the left eye, and the exam was done during the post-op period on the right eye, you could use 92012-24-RT for the exam, if its an established patient, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., based in Spring Lake, NJ. The reason for the modifier -RT is to tell the payer that there is something unusual, says Brink. The -24 modifier should be used as well, because that tells the payer that the procedure is unrelated to the initial surgery, she says. The -24 modifier is a payment modifier; the -LT and -RT are information modifiers only.

Barbara Cobuzzi, CPC, president of Cash Flow Solutions Inc., a Lakewood, NJ-based medical billing and consulting firm, recommends using both the -24 modifier and the -LT or -RT. You should show the -24 first, and then the -LT or -RT, says Cobuzzi. But you need to show its a different eye, or they wont know.

If you are already using the -24 modifier for this situation and getting the exam denied, definitely use the -LT or -RT, urges Cobuzzi. If that still doesnt work, you may have to do a post-payment appeal. And if that doesnt work, go right to the next level -- a fair hearing, she says. A lot of times they just dont read what youre sending, even on post-payment appeal, she adds. When you go to a fair hearing, and they see the notes and the pictures, they get it -- and they pay. This problem is particularly true for modifier -24, says Cobuzzi.

(Tip: Modifier -24 is only for an E/M services code, explains Brink. If you are using an ophthalmology code for the exam, you cannot use modifier -24. Also, the -LT and -RT are Medicare codes; if the patient is covered by commercial insurance, the company may not recognize the -LT/-RT distinction.)

You also need to be specific with diagnosis codes. The diagnosis code for the right eye could be the same as it was for the left eye, or it could be different, says Brink. You need to specify what kind of cataract youre talking about.

2. Surgery only (plus one-day post-op).
Sometimes an ophthalmologist performs cataract surgery as a specialist, and the patient goes back to his or her regular physician for the follow-up. The surgeon also sees the patient the day after the surgery. In the case of 66984 (extracapsular cataract removal with insertion of intraocular lens prosthesis), a surgeon does the surgery only. The question is, how to code for seeing the patient one day post-op, which is the standard of care for the surgeon?

First of all, we have to answer the question of how to code the surgery only, and the post-op care only. The answer is clear in CPT. The surgeon can use the -54 modifier, and the physician who sees the patient for the 89 days afterward charges the -55 modifier, says Cobuzzi. The surgeon will get a 15 percent reduction in the global 66984, and the other physician will get that 15 percent.

Modifier -54 is for surgical care only, and modifier -55 is for postoperative management only. But in the real world, this is sometimes difficult to coordinate, says Cobuzzi. How does the ophthalmologist, (or possibly other physician) who is doing the post-op care know how the surgery was coded? she asks. The ophthalmologist has to know to submit the -55 modifier, and he cant know that unless he or she knows how the surgeon submitted the claim. An added problem is that surgeons loathe using the -54 modifier because of the fee reduction, says Cobuzzi. Also, the patient has to want to go to a different doctor for post-operative care.

But lets say you do get to the point of using the -54 and -55 modifiers. Now the question is, if you are the surgeon, and you see the patient for one day post-op, how do you get paid for that day? The answer is to bill until the patient is transferred. Each postoperative day has a value. It used to be that the non-operating surgeon billed for each day starting from the first day he actually saw the patient; HCFA had said it wasnt proper to bill until the patient had been seen. But that policy has been liberalized at the request of a number of Medicare carrier directors. Now, the date of transfer determines when the receiving physician can begin billing. The operating physician tells the patient, You can start seeing Dr. So-and-So tomorrow, and from the next day on, the non-operating physician can start billing -- even if he or she does not actually see the patient on that date. The operating surgeon bills for the surgery with the -54 modifier, and then he can also bill for postoperative visit days. The fact that the patient wants to go to the non-operating physician for postoperative days should be documented in the chart.

3. Surgery during 90-day post-op period: -79 or -58?
Now for our last scenario. One month after cataract surgery of the left eye, you need to perform surgery on the right eye. What is the proper modifier to use in this situation?

If you are performing a trabeculectomy (66170) for glaucoma within 90 days of a cataract extraction, you would use modifier -79 (unrelated procedure or service by the same physician during the postoperative period, CPT 1999).

If, however, you are performing a trabeculoplasty by laser (65855) first, and following it by a trabeculectomy (66170), you would use modifier -58, because this is for a related procedure.