Ophthalmology and Optometry Coding Alert

When evaluating a patient who had cataract surgery in one eye, code the visit for the second eye based on carrier rules. There's no national policy regarding this visit. Some payers will cover it, based on medical necessity.
 
Many payers don't allow billing the visit at all. They say the second eye was evaluated when the first was examined; hence, the preoperative evaluation was already performed.
 
Even though there are two surgeries, you don't get paid for two decisions for surgery. You make the decision for both at the same visit, the initial one.
Postoperative or Preoperative Visit
For example, a patient has bilateral cataracts. At the initial evaluation, during which the ophthalmologist determines that the reason the patient's vision is deteriorating is cataracts in the eyes, the physician and patient agree that one eye will be operated on first and the second eye will be operated on later. During the first surgery's postoperative period, the ophthalmologist evaluates the patient for the second surgery. Is the visit primarily for postoperative care for the first surgery, or for examining the second eye? It's probably for both, which would technically, at least allow appending either modifier 24 (unrelated E/M service by the same physician during a postoperative period) or -57 (decision for surgery), says Melissa K. Duchak, CPC, practice administrator for Bruce E. Kanengiser, MD, an ophthalmologist in Piscataway, N.J. But many carriers say this visit in which you evaluate the second eye is actually a postoperative visit for the first eye. You can't bill for it.
 
The carriers that normally don't pay for the second evaluation within the postoperative period of the first surgery established two criteria for covering that visit: (1) new symptoms in the second eye, or (2) a significant change in health that requires a new preoperative examination. If at least one of the criteria is not satisfied and the visit for the second eye is within the postoperative period of cataract surgery for the first eye, you will not get paid. These carriers also demand that all documentation supporting these indications be submitted with the claim.
 
Most often, both eyes need cataract surgery, and the second eye is done within 90 days of the first. Typically, the patient is so happy with the first eye that he or she doesn't want blurry vision in the other eye and requests the additional surgery as soon as possible. Assuming all the medical-necessity criteria are met for cataract surgery on the second eye, it is usually operated on within the 90-day global period of the first eye.
E/M Code for Second Eye Evaluation
Some Medicare carriers are more generous, and say that an E/M code, usually 99213 (level-three established patient office visit), should [...]