Optometry Coding & Billing Alert

Published on Fri Jan 07, 2005 PDF

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If you find yourself drowning in a sea of codes and modifiers, read on for a lifeline

The more tests you have to perform on a glaucoma patient, the more complicated your CPT and ICD-9 coding gets, as an Arizona optometrist in a Health Professional Shortage Area (HPSA) recently learned. No matter how many coding guides and resources you collect, there's always a coding dilemma that just won't fit neatly into the scenarios described in CPT.

See how our experts approach this one-of-a-kind conundrum and apply these concepts to your difficult cases.

Patient: New patient presenting with borderline open-angle glaucoma OU, dry-eye syndrome and eye pain.

Procedures: Comprehensive eye exam, gonioscopy, corneal pachymetry, OCT, and full threshold visual fields.

ICD-9 coding: The diagnoses of dry-eye syndrome (375.15, Tear film insufficiency, unspecified) and eye pain (379.91, Unspecified disorder of eye and adnexa; pain in or around eye) are not sufficient to prove medical necessity for all four tests. Instead, link those two ICD-9 codes to the eye exam-reported with an E/M code (99201-99215) or an eye code (92002-92014) - since they represent the complaints that brought the patient into the office.

The proper diagnosis to link to all four tests is 365.01 (Borderline glaucoma [glaucoma suspect]; open angle with borderline findings).

Especially with Medicare" you will want to tie your diagnosis to your patient's complaint " says David Gibson OD FAAO practicing optometrist in Lubbock Texas. "The gonioscopy the corneal pachymetry the OCT and the visual fields can all be justified from what the doctor found during the initial eye exam assuming he found signs or history of glaucoma but the exam diagnosis code should relate to the complaint."

CPT coding: Report the following codes linked to ICD-9 code 365.01 for the tests:

92083 (Visual field examination unilateral orbilateral with interpretation and report; extendedexamination [e.g. Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30o or quantitative automated threshold perimetry Octopus program G-1 32 or 42 Humphrey visual field analyzer full threshold programs 30-2 24-2 or 30/60-2]) for the full-threshold visual fields

92135 (Scanning computerized ophthalmic diagnostic imaging [e.g. scanning laser] with interpretation and report unilateral) for the OCT

92020 (Gonioscopy [separate procedure]) for thegonioscopy

76514 (Ophthalmic ultrasound diagnostic; cornealpachymetry unilateral or bilateral [determination of corneal thickness]) for the corneal pachymetry.

Pitfall: The above codes are not bundled according to the National Correct Coding Initiative but you should wait to perform the visual fields during a future visit because Medicare frowns on performing them on the same day as OCT says Charles Wimbish OD president of Wimbish Consulting Group in Martinsville Va.

Hidden trap: Carriers consider visual fields gonioscopy and corneal pachymetry to be inherently bilateral says Mem O'Shea billing manager for Bruce Levinson OD of Syracuse N.Y. - the amount they reimburse for those procedures is already based on the work being done on both eyes. Therefore report 92083 92020 and 76514 only once each on your billing form and do not append modifiers to the codes that indicate bilateral tests.

CPT code 92135 however is considered inherently unilateral O'Shea says. If you scanned both retinas you should report the code on one line appended with modifier -50 (Bilateral procedure) or on two lines appended with the -LT and -RT modifiers to indicate that the procedure was performed on both eyes.

Don't forget: Since this optometrist practices in a HPSA he's entitled to an incentive payment of 10 percent from Medicare - but only on the professional component of the services. To qualify for payment for the technical component report 92135-26-50-QU (Professional component; bilateral procedure; physician providing service in an urban HPSA) for the professional component (appending modifier -50 to indicate a bilateral test and-QU to indicate your HPSA status) and 92135-TC-50 (Technical component) on the second line of the billing form for the technical component.

Append modifier -QU if you practice in an urban HPSA; if you practice in a rural HPSA append -QB (Physician providing service in a rural HPSA). The same rules apply for 92083 and 76514. "HPSA is only paid on the professional service not the technical component " Gibson says. "If you don't separate the code you won't receive the premium on any of the fee."

Do this: Check with your carrier for policies on 76514 frequency. Many carriers will only reimburse for pachymetry once in a lifetime for each glaucoma patient per doctor says Teresa Turrentine administrator for Lifetime Vision Source in Lebanon Ore.

The coding scenario: Depending on whether your carrier prefers the right and left modifiers or the bilateral modifier the coding for this complete scenario would look like one of these:

Diagnosis (Dx) Codes:
1. 365.01 2. 375.15 3. 379.91

Procedures (using -RT/-LT) Dx
1. 92004-QU 1 2 3

2. 92020-QU 1

3. 76514-26-QU 1

4. 76514-TC 1

5. 92135-RT-26-QU 1

6. 92135-RT-TC 1

7. 92135-LT-26-QU 1

8. 92135-LT-TC 1

Procedures (using -50) Dx
1. 92004-QU 1 2 3

2. 92020-QU 1

3. 76514-26-QU1

4. 76514-TC1

5. 92135-26-50-QU1

6. 92135-TC-501

Next visit: Bill 92083-26-QU linked to 365.01.

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