Ophthalmology and Optometry Coding Alert

When two ophthalmologists are performing surgery on the same patient at the same time, doing two separate procedures, what modifier should you use so they can both get paid? We regret to report that the answermodifier
-80 (assistant surgeon) or -81 (minimum assistant surgeon)wont always help you.

Take the case of Francois D. Trotta, MD, of Boise, ID, who assisted at a surgery of a Medicare patient who needed a lensectomy (66940) and a posterior vitrectomy (67036). A different ophthalmologist performed the lensectomy; Trotta, a retinologist, did the posterior vitrectomy. Both surgeons remained with the patient during the entire process, writes Janet Meyers, Trottas office manager. Which modifier should be used?

Unfortunately, it doesnt matter which of these two modifiers you use, because Medicare wont pay for these two procedures to be done together, reports Patricia Santos, billing supervisor for Charles White, MD, of Wareham, MA. Youll only get paid for doing one of those, says Santos. This is because there is one code that includes both of these procedures when both are performed pars plana (66852). The payer turndown does not relate to the procedures being bundled under the Correct Coding Initiative (CCI). Medicare requires that if there is one code that includes the parts of a procedure, you may not use two or more codes to describe the procedure. However, it is often true in these cases that the lens is removed by phacofragmentation (66850) and not by the pars plana method. Getting the codes and modifiers right for these scenarios is crucial to correct payment.

Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY, has the following advice on how to code several related scenarios involving two surgeons during the same procedure.

1. Two surgeons, two pars plana procedures.
If both procedures were performed pars plana and two surgeons were medically necessary to perform the case, then the -62 modifier (two surgeons) for co-surgery applies and not the -80 or -81. Each surgeon will submit a bill that looks exactly the same: 66852-62. Medicares payment policy for co-surgery is to allow 125 percent of the normal Medicare Fee Schedule and divide the payment equally (50/50) between the two surgeons. One operative report can be dictated by either surgeon as long as it lists both surgeons as primary and the body of the operative note reflects clearly which portions of the procedure each surgeon performed, Roberts says. Also, since medical necessity for two surgeons is an issue in these cases, an indications section at the beginning of the report may be useful to make the medical necessity issues clear.

A well-dictated operative report is crucial because these claims are often denied or one is paid and [...]