Ophthalmology and Optometry Coding Alert

Question: In reference to 76519-26 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) and 92012 -26 (ophthalmological services; medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient), please tell us why Medicare will not pay even though we use modifier -26 (professional component) for indication of this being for surgery on the second eye. Our experience is that Medicare pays the 76519-26 at a very reduced rate, and the 92012-26 is disallowed completely. Please tell us if there is a better way of coding.

Carol Conerly, Office Manager
Kebert Eye Clinic
McComb, Miss.

Answer: Modifier -26 (professional component), which is for the professional, or physician, component (as against the technical or ultrasound component) should never be used with 92012. The eye exam doesnt split professional and technical components; 92012 is a stand-alone code. Medicare is probably rejecting this charge either because it does not recognize 92012 with the -26 modifier appended or because the visit is being billed inside the global period of the first eye.

Medicare considers that if the second eye is done in the global period of the first eye, the initial determination to do the second eye was made at the same time as the first eye determination. Therefore, the examination is denied for the second eye because it is considered the preoperative examination portion of the global package for the second eye.

For the ultrasound itself, however, the modifier -26 is appropriate. Thats because 76519 has a technical and a professional component. When the A-scan was done on the first eye, the ophthalmologist could bill the global 76519 for the technical and the
professional component.

For the second eye calculation done within a year of the measurements, however, the technical portionthe A-scanwas already performed. You would only bill for the professional component. Billing 76519 would indeed reduce your fee because you are only being paid for the professional service of determining the power and style of IOL implant. Medicare would pay about $29 for 76519-26. For 76519, both components, Medicare reimburses approximately $76.

Tip: Try attaching the eye modifiers, -RT and -LT, to the A-scan codes so Medicare understands that the second eye is being billed.

Sources for Answers: Sue Vicchrilli, COT, ophthalmic coding specialist, American Academy of Ophthalmology; Lise Roberts, vice president, Health Care Compliance Strategies.