Ophthalmology and Optometry Coding Alert

Question: We recently purchased the Retina Tomograph II. I know that the procedure code is 92135 and is unilateral. Do I receive full reimbursement for both eyes, or is it 100 percent for the first and 50 percent for the second? Would I bill this as 92135-50? Also, how do I code a subsequent 92135? Do I use a -26 modifier? What is considered subsequent? More than one a year, or every time after the initial 92135?

Georgia Subscriber

Answer: You are correct, 92135 (scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) is a unilateral code in the Medicare program. As a unilateral testing code, when two services are billed to Medicare, both services are supposed to be approved at 100 percent of the Medicare fee schedule amount.

Most Medicare carriers prefer that you bill the services as one-line item with the -50 modifier, 92135-50, but check with your carrier to be sure. Typically, when the -50 modifier is applied to a code, the claim system generates an approved amount of 150 percent according to the bilateral surgical procedure payment rule, and it is for only a handful of codes that an approved amount of 200 percent is allowed. Be careful to review the EOMB (explanation of Medicare benefits) to make sure the carrier has approved the services for a total of 200 percent, not 150 percent. If the carrier is paying only 150 percent when you submit a single-line item with the -50 modifier, change your billing protocol to a two-line item entry: 92135-RT and 92135-LT. In regard to subsequent testing, the same CPT code is used, 92135, and a modifier is not required.

When billing for subsequent testing services, it is not necessary to make a distinction that the service is initial or subsequent. In ophthalmology, only one testing service has the language initial and subsequent, which is extended ophthalmoscopy, codes 92225 and 92226.

In regard to frequency, most Medicare carriers have a local medical review policy (LMRP) for 92135. Most policies allow for a combination of Optic Disk Scanning and Visual Field testing during a calendar year, depending on the patients condition. Contact your local Medicare carrier for its LMRP.