Optometry Coding & Billing Alert

Published on Sun Jan 08, 2006 PDF

Find answers for your bilateral billing questions for common optometry procedures

Keeping track of Medicare's rules for bilateral billing of ophthalmic procedures just got easier. No more wading through the entire Physician Fee Schedule, looking for the -Bilateral Surgery Indicator- for a specific code -- find all the information you need in this simple chart.

Medicare assigns -Bilateral Surgery Indicators- to all of the CPT codes to indicate whether the code is subject to a payment adjustment if you report it bilaterally. These indicators tell you whether you have the option of reporting a code bilaterally or unilaterally.

Bilateral Procedure Indicator -0-:

Do not report these codes bilaterally.
92311, 92313, 92315, 92317, 92325, 92326, 92499

For optometry procedures marked with indicator -0,- the bilateral adjustment does not apply because the code descriptor specifically states that it is a unilateral procedure (e.g., 92311, Contact lens fitting; corneal lens for aphakia, one eye), and there is an existing code for the bilateral procedure (e.g., 92312, - corneal lens for aphakia, both eyes), says Sunshine Weihert, OCS, coder for Kings Eye Center in Hanford, Calif.

Bilateral Procedure Indicator -1-:

You may report these codes bilaterally.
65205, 65210, 65220, 65222, 65430, 65435, 67820, 67938, 68761, 68801

Report procedures such as foreign-body removal (65205-65220) or punctal plugs (68761) bilaterally, says Weihert. Medicare will base payment on 150 percent of the fee schedule amount for a single code (or for your total charge for both codes, if that happens to be lower).

Bilateral Procedure Indicator -2-:

Do not report these codes bilaterally.
76514, 76516, 76519, 76519-TC, 92020, 92060, 92065, 92081, 92082, 92083, 92100, 92120, 92130, 92136, 92136-TC, 92140, 92250, 92260, 92265, 92270, 92275, 92283, 92284, 92285, 92286, 92287, 92312, 92316

Medicare sets the RVUs for these procedures based on their being performed bilaterally. In most cases, the code descriptor states that the procedure is bilateral (or that it may be performed unilaterally or bilaterally), or the procedure is usually performed bilaterally.

If a procedure is divided into a professional component (modifier 26) and a technical component (TC), the components usually have the same bilateral status. Note the exceptions of 76519 (A-scan; with intraocular lens power calculation) and 92136 (Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation). Medicare views the technical components of these procedures as inherently bilateral (indicator 2), meaning that the payment for 76519-TC or 92136-TC is based on the procedure being performed bilaterally. However, since the optometrist may measure the IOL strength in just one eye, 76519-26 and 92136-26 are unilateral (indicator 3) -- the payment includes the professional component performed on only one eye.

Bilateral Procedure Indicator -3-:

You may report these codes bilaterally.
76510, 76511, 76512, 76513, 76519-26, 76529, 92070, 92135, 92136-26, 92225, 92226, 92230, 92235, 92240

If you perform these procedures on both eyes, you can report them once per eye, says Marsha Duggins, billing coordinator for Whitson Vision in Indianapolis. Medicare will not apply the usual downward payment adjustment for bilateral procedures, reimbursing you the full amount for each eye. Note that A-scan code 76519-26 and IOL calculation code 92136-26 are in this category, as mentioned above.

Bilateral Procedure Indicator -9-:

The bilateral concept does not apply.
92015, 92310, 92314, 92340, 92341, 92342, 92352, 92353, 92354, 92355, 92358, 92370, 92371

Most of the codes marked with indicator -9- are for contact lens fittings, in which the bilateral concept would indeed not apply.

Find it online: The bilateral surgery indicators for all of the CPT codes are in Column T of the Physician Fee Schedule Database File. To download the complete Physicians Fee Schedule, visit the Medicare Web site at www.cms.hhs.gov/PhysicianFeeSched.