Ophthalmology and Optometry Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.


The Case: If a patient who has surgery by another physician comes to see one of our physicians for post-operative care during the post-op period and we have no co-management agreement with the surgeon, how should this claim be filed?

Michelle Green, Insurance Manager
Cooksey and Perry Ophthalmology
Monroe, La.


The Answer: The Health Care Financing Administration (HCFA) says that if a patient shows up in another physicians office for follow-up post-op care, and there is no agreement for the transfer of care with the surgeon, then the services should be billed on a visit-by-visit basis using the evaluation and management codes or the eye exam codes. As long as there is no pattern where patients always have their surgery with Dr. X and then end up in Dr. Ys office for follow-up care billed on a visit-by-visit basis, then everything is OK and both doctors get paid.

For commercial payers, you may have to take a different route: there are two possible ways to handle that situation. One is to bill for the office visit, using V67.0 (follow-up examination following surgery) for the primary diagnosis code, and the diagnosis for the surgery as the secondary diagnosis code. No modifier is needed. You file the claim, prepared to appeal it with documentation that the patient has chosen to do post-op care with you. The payer will still prorate the fees just as if the care had been co-managed from the start, but it will take some time.

The other option is to be up front about what is happening. File a paper claim from the beginning, along with a letter explaining that you know this is an abnormal situation, but that the patient has chosen to do the follow-up care with you, and there is no co-management agreement (so the surgeon filed for the full fee with no modifier). The payer will again prorate both your fee and that of the surgeon, as if you had both used the -54 (surgical care only) and -55 (postoperative management only) modifiers.

Tip: Its a good idea for you to communicate with the surgeon, as well, partly from a patient care perspective, but also because the payer will be asking the surgeon to pay them back for whatever post-op care they are paying you to provide.