Optometry Coding & Billing Alert

Published on Thu Jul 08, 2004 PDF

Confusion about coding eyelash removal can be a thing of the past if you can keep up with these modifiers

Epilation for trichiasis - the removal of uncomfortable misdirected eyelashes that grow in toward the eyeball -- can be a difficult procedure to code because different carriers demand different methods of billing. Coding epilation becomes even more daunting if your optometrist completes the procedure bilaterally or on multiple eyelids, or if more than one eyelash is removed.

The first step to correct coding is to determine your payer's accepted billing method. There are three methods of coding epilation -- per eye, per eyelid, and per lash -- and your payer will only reimburse you for claims submitted by one of these methods.

Typically, private payers consider billing per eye to be the correct way to handle epilation coding. Some Medicare carriers, such as Noridian Mutual of Arizona, however, pay by the eyelid. Trailblazer of Texas, Maryland, Delaware, Virginia and Washington, D.C., on the other hand, considers 67820 (Correction of trichiasis; epilation, by forceps only) to be a bilateral procedure but allows billing of 67825 (... epilation by other than forceps [e.g., by electrosurgery, cryotherapy, laser surgery]) up to twice per eye. You may even come across a carrier with an policy that permits billing per lash.

If the carrier denies an initial claim, "the next step is to send in a note," says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. "If they kick it back again and say, 'Sorry, we just don't pay this number,'then you've got your carrier interpretation. You're not going to get that by calling customer service and asking how many times they'll pay this procedure, because often they're not even allowed to tell you that anymore."

If the carrier pays per eye, you should use the correct epilation code, 67820 or 67825, with the correct eye modifier, -RT or -LT, or modifier -50 (Bilateral procedure) if performed on both eyes.

Jackie Rice, accounting and insurance manager for The Eye Specialists in Virginia Beach, Va., codes per eye regardless of the carrier. If carriers reject claims, "We'll go back to them with more information," she says. "Usually, we don't have a problem."

For example, your carrier has a local medical review policy that allows billing by eye, and your optometrist, by use of forceps, removes one lash from a patient's left lower eyelid and two lashes from the same patient's right upper eyelid. You should code 67820-50 if the carrier is Medicare, and 67820-LT, 67820-50-RT for private carriers.

If you are submitting a claim to a carrier that permits billing by eyelid, you have twice as many modifiers (and twice the number of reimbursement possibilities) than when billing epilation per eye. Coding per eyelid is the method used by Joanne Augustine, insurance and billing coordinator for the Eye Center at the Southern College of Optometry in Memphis.

The eyelid modifiers you should use are -E1 (Upper left, eyelid), -E2 (Lower left, eyelid), -E3 (Upper right, eyelid) and -E4 (Lower right, eyelid), Augustine says.

For example, a patient presents with trichiasis of two lashes of her upper left eyelid, one lash of her lower left eyelid, and one lash of her lower right eyelid. The severity of the irritation to the patient's eyes constitutes medical necessity for removing the lashes. The optometrist performs epilation of all the lashes. The procedures should be coded 67825-E1, 67825-51-E2, 67825-51-E4.

The multiple-procedures modifier -51 is used here to indicate that lashes were removed from multiple eyelids.

As for payment, you are allowed the full fee for the first line billed, and 50 percent of the fee schedule for the second and third lines billed -- more than if you use CPT's coding-per-lash guidelines.

On the rare occasion when your carrier's epilation LMRP allows you to code by lash, use your knowledge of the local lash modifiers to wow your fellow coders. The lash modifiers begin with -Y2 for the first lash removed and continue to -Y9 for the eighth. For lashes nine and 10, use -Z2 and -Z3 respectively. You should then append modifier -99-U2 for the 11th lash as well as any additional lashes (-99, Multiple modifiers).

Coding for epilation "changes every time Medicare reviews the code," says David Gibson, OD, FAAO, of Lubbock, Texas. "When we first started billing the code, [67820] was a monocular code. Then, we got paid more for each eye than we get now for both eyes together. The code was changed from a monocular definition to a multiple-surgery code, where the second eye paid at 50 percent, to now being a binocular code receiving one payment. The next thing you know, it could wind up being a bundled code under the 99000 [Miscellaneous services] codes."