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.


Question: We send our patients who need fundus photos or fluorescein angiography to the hospital next door. They take the photos and send them to us without interpretation. Is there a way to bill Medicare (and/or private insurance) for the interpretation only?

Alabama Subscriber


Answer: In the Medicare program, payment for testing services that have the term with interpretation and report in their code description is allocated separately for the testing procedure and the physicians interpretation.

Heres a Medicare example: 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report) includes the test itself as 92235-TC (with the -TC modifier indicating the technical component) and the interpretation as 92235-26 (with the modifier -26 indicating the professional component).

If you bill the service without the modifiers -TC or -26, the carrier will assume that both services were provided; 92235-TC + 92235-26 92235. If you want to bill for the professional component for the physicians interpretation only, you will need to bill 92235-26, and advise the hospital to bill only 92235-TC. This will instruct the carrier to pay the hospital for the test and you for the interpretation.

What if the patient is covered by private insurance and not Medicare? Commercial insurance companies probably will not recognize the -TC and -26 modifiers. You may want to establish a relationship with the hospital to purchase the tests from them at a set fee with the understanding that they will not bill the patient or insurance company for the service. Then you can bill the entire service to the insurance company or patient. If you do this, you will need to indicate on the claim form in the block for outside laboratory yes or no an answer of yes.

For Medicare patients, if you had an agreement to purchase the test from the hospital, you should check with your Medicare carrier for any alpha modifiers with two characters they might require for billing purchased tests. Such modifiers are assigned by each individual Medicare carrier.