Ophthalmology and Optometry Coding Alert

There's no business like strabismus, especially when billing bilaterally can save you $160 per procedureCoders -- especially those for pediatric ophthalmologists -- know how difficult sorting out the various eye muscles involved in strabismus surgery can be. With 12 ocular muscles to keep track of, one simple coding mistake could cost your practice hundreds, unless you know the ropes.Make Modifier 50 Your Secret WeaponScenario: An ophthalmologist removes a 6.5-mm section of the lateral rectus muscle of the patient's left eye and resects the muscle to strengthen it and correct strabismus. He then repeats the procedure on the right eye, again removing 6.5 mm of the lateral rectus muscle and then resecting it. Two different codes might look correct -- but only one will bring you the reimbursement you deserve.Be careful: Because the ophthalmologist performed a resection procedure on two horizontal muscles, 67312 (Strabismus surgery, recession or resection procedure; two horizontal muscles) may look correct, but don't fall into this trap.The strabismus surgery codes (67311-67318) describe procedures done in one eye only. Although the surgeon did resect two muscles, they were in different eyes, so 67312 is not correct.Instead, you should report 67311 (Strabismus surgery, recession or resection procedure; one horizontal muscle) bilaterally, says Riva Lee Asbell, ophthalmic coding and reimbursement educator and principal of Riva Lee Asbell Associates in Ft. Lauderdale, Fla., who led the "Strabismus Surgical Coding Challenges" seminar at The Coding Institute's Ophthalmology Coding and Reimbursement Conference in March. Most Medicare carriers want you to report the entire session on one line with modifier 50 (Bilateral procedure) and a "1" in the units field.Warning: Reporting 67312 would even hurt your reimbursement in this case. In the Medicare physician fee schedule, 67311 has a "1" bilateral status indicator. That means Medicare will allow you to report bilateral services and will process them for payment, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, with MJH Consulting in Denver.If you report 67311-50 or two instances of 67311 on two lines -- for example, 67311-LT for the left eye and 67311-RT-51 (Multiple procedures) for the right -- Medicare will base payment on 150 percent of the fee schedule amount for a single code.Medicare multiplies the facility relative value units (RVUs) for 67311 (13.72) by the conversion factor of 38.0870, arriving at $522.55. Appending modifier 50 for the bilateral procedure means that Medicare would reimburse you 150 percent of that, giving you $783.83 (unadjusted for geographical location).Reporting 67312, however, even though the descriptor mentions "two horizontal muscles," will short-change you. With no bilateral pay adjustment, the RVUs for 67312 would only bring in $623.87.Select a Single Code for Single-Eye MusclesTo code strabismus surgery correctly, you also need to know when you can [...]