Ophthalmology and Optometry Coding Alert

Question: If we examine a glaucoma patient for IOP pressure check only, and decide to perform an argon laser trabeculoplasty (65855) in the right eye on the same day, how do we code these services? Is it 99212-57 and 65855-RT?

Anonymous Pennsylvania Subscriber

Answer: Yes, although you might have performed a higher-level office visit and should code accordingly. You should put the modifier -57 (decision for surgery) on the office visit to indicate that you made the decision for surgery that day, and that surgery will be done within one day.

However, its likely that you would code a higher level than 99212 for the office visit, since the medical decision-making for surgery is at least low, and it is likely that a thorough examination of all the anterior segment structures of the eye took place. You might code a level three or four depending on the documentation, but nothing as high as a level five, unless the patient was having an acute angle attack.

A gonioscopy would probably be done that day as well. So you would bill the trabeculoplasty with the eye modifier (65855-RT), the office visit with the modifier
-57, and the gonioscopy (92020) with no modifier. The diagnosis code for all three procedure codes would be whatever the form of glaucoma was (e.g., primary open angle glaucoma).