Ophthalmology and Optometry Coding Alert

Bilateral procedures are common in ophthalmology practices, since medical issues often affect both eyes. While it may sometimes be challenging to evaluate when the bilateral billing rules apply and when they don’t, you can find all of this information in the Medicare Physician Fee Schedule.

However, you don’t necessarily need to pull up the entire fee schedule for guidance to understand when you can append modifiers 50 (Bilateral procedure), LT (Left side), or RT (Right side). Instead, we’ve broken down several eye care-specific codes according to whether the fee schedule lists them with a 0, 1 or 2, 3, or 9 indicator in the “BILAT SURG” column.

Check out what each indicator means, and see samples of the codes that fall into those categories.

0 or 3: Bilateral surgery rules do not apply, and you should not append modifier 50.

For instance, the following codes fall under the 0 indicator rules:

• 66990 (Use of ophthalmic endoscope (List separately in addition to code for primary procedure))
• 67221-+67225 (Destruction of localized lesion of choroid (eg, choroidal neovascularization);…)
• 92018-92019 (Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination…)
• 92325 (Modification of contact lens (separate procedure), with medical supervision of adaptation)

And these are among the codes that fall under the 3 indicator rules:

• 76510-76513 (Ophthalmic ultrasound, diagnostic…)
• 76529 (Ophthalmic ultrasonic foreign body localization)
• 92136-26 (Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation, Professional component)
• 92230 (Fluorescein angioscopy with interpretation and report)

When billing any of the above services, do not use a bilateral modifier on your claim.

1: Bilateral surgery rules apply, and you can use modifier 50 or the LT/RT modifiers.

The following codes are among those that fall under indicator 1 rules:

• 65205-65265 (Removal of foreign body…)
• 65770 (Keratoprosthesis)
• 65800-65815 (Paracentesis of anterior chamber of eye (separate procedure)…)
• 67400-67414 (Orbitotomy without bone flap (frontal or transconjunctival approach…)

When reporting the above services, you can use either modifier 50 or LT/RT modifiers to the claim.

2: The code already specifies a bilateral procedure.

These codes are among those listed in category 2:

• 76516-76519 (Ophthalmic biometry by ultrasound echography…)
• 92020 (Gonioscopy (Separate procedure))
• 92065 (Orthoptic and/or pleoptic training, with continuing medical direction and evaluation)
• 92081-92083 (Visual field examination, unilateral or bilateral, with interpretation and report)
• 92136

For the above codes, you should not append modifier 50, LT or RT to denote a procedure’s bilateral nature. Bilateral payment is already included in the relative value units (RVUs) for these codes.

9: The bilateral surgery concept does not apply.

The following codes are examples of codes in this category:

• 65760 (Keratomileusis)
• +65757 (Epikeratoplasty)
• 65771 (Radial keratotomy)

Note: If a procedure is divided into professional (modifier 26) and technical components (modifier TC), the components usually have the same bilateral status — but not always. For instance, one notable exception is 92136, which has a bilateral indicator of 2, whereas 92136-26 has a bilateral indicator of 3.

Medicare views the technical components of these procedures as inherently bilateral, meaning that the payment for 92136-TC is based on the procedure being performed bilaterally. However, since the physician may measure the IOL strength in just one eye, 92136-26 is unilateral.