Ophthalmology and Optometry Coding Alert

CMS announces changes to bilateral status for epilation and lesion excision Misinterpreting the bilateral status of procedures like epilation or eyelid repair can have tragic consequences for your practice's bottom line. Soon, keeping the status straight will be a lot simpler - Medicare plans to update the fee schedule in July so that all of the "Eye and Ocular Adnexa" CPT codes (65091-68899), with only 10 exceptions, will have the same bilateral status.
 
Thanks in part to lobbying by the American Academy of Ophthalmology (AAO), two recent CMS transmittals announced updates to the Physician Fee Schedule Relative Value Database that will change the bilateral status of a total of 59 ophthalmological CPT codes.
 
Watch for: Transmittal 558, published on May 6, 2005, changes the bilateral status of 13 procedures from "0" to "1." The implementation date for the update is July 5, 2005, for procedures performed on or after Jan. 1, 2005. The changes will appear in the July 2005 revision of the fee schedule.

The effected CPT codes are:
   67810 - Biopsy of eyelid
   67825 - Correction of trichiasis; epilation by other  than forceps (e.g., by electrosurgery, cryotherapy, laser surgery)
   67830 - ... incision of lid margin
   67835 - ... incision of lid margin, with free mucous membrane graft
   67840 - Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure
   67850 - Destruction of lesion of lid margin (up to 1 cm)
   67875 - Temporary closure of eyelids by suture (e.g., Frost suture)
   67880 - Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy
   67882 - ... with transposition of tarsal plate
   67900 - Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
   67930 - Suture of recent wound, eyelid, involving   lid margin, tarsus and/or palpebral conjunctiva direct closure; partial thickness
   67935 - ... full thickness
   67938 - Removal of embedded foreign body, eyelid.
 
What this means: Modifier indicator "1" means that the 150 percent adjustment for bilateral procedures applies. If you code any of these procedures with the bilateral modifier or report them twice on the same day by any other means (e.g., with -LT and -RT or with a "2" in the units field), Medicare carriers will base payment on the lower of the total actual charge for both sides, or 150 percent of the fee schedule amount for a single code, says Kathryn Drechsler, CPC, coder for the Bascom Palmer Eye Institute at the University of Miami.
 
The previous status of "0" attached to these codes prevented the 150 percent adjustment from being applied,  Drechsler says. Carriers based payments on the total fee schedule amount for one code.
 
Note: To download this transmittal, visit www.cms.hhs.gov/manuals/pm_trans/R558CP.pdf. Report Most Eyelid Reconstructions Bilaterally An earlier CMS ruling, Transmittal 475, effective April 5, changed the bilateral status for 46 [...]