Optometry Coding & Billing Alert

Published on Fri Jun 04, 2010 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." Note: The code description for 76514 includes the phrase "unilateral or bilateral," which appears in many procedure codes. This phrase means that Medicare  and most payers  will pay the same whether you perform the procedure on one or both eyes.

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.