Optometry Coding & Billing Alert

Published on Thu Jul 08, 2004 PDF

Question: I'm trying to submit a claim for 76514 performed on both eyes, but I've been getting conflicting information. One payer representative told me to code 76514 on two lines, appending modifiers -LT and -RT. Another one said that it's already considered a bilateral procedure and that I should only code it once. Another coder told me to append modifier -50 (Bilateral procedure). What's the proper way?

Nebraska Subscriber

Answer: You should only code it once. The Physician Fee Schedule Database gives 76514 (Ophthalmic ultrasound, echography, diagnostic; corneal pachymetry, unilateral or bilateral [determination of corneal thickness]) a bilateral surgery indicator of "2," which means "150 percent payment adjustment for bilateral procedure does not apply."

Kansas Medicare clarifies further in its payment policy indicator manual: "RVUs are already based on the procedure being performed as a bilateral procedure. "If [the] procedure is reported with modifier -50 or is reported twice on the same day ... the carrier will base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code." In other words, you'll only get paid once for 76514.

By the same token, if you perform the test on only one eye, it is not necessary to append modifier -52 (Reduced services) to the CPT code. Some Medicare carriers may require modifiers -LT or -RT when billing a bilateral code for one eye only. These carriers will most likely reduce your fee by 50 percent. If the carrier requires modifier -52, it will not reduce your payment. Private payers, however, may pay less if you append modifier -52.