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Ophthalmological Question--E&M during cataract post-op period

  1. Default Ophthalmological Question--E&M during cataract post-op period
    Medical Coding Books
    Good Morning,

    I am trying to determine what the typical behavior and expectation for reimbursement is on E&M services provided by ophthalmologists in the post-op period for a cataract surgery.

    Here's the general scenario:

    1. The provider performs surgery to remove a cataract in one eye, perhaps the left to start.

    2. The provider sees the patient in the post-op period to check the left eye, however, also checks the right eye, and decides to proceed with cataract surgery for the right eye. The provider schedules the patient a time for the next surgery.

    Currently, the payor I work for denies the claim for item number 2, as part of the global for the cataract surgery. Even when the 24 modifier is appended to the claim, it denies through system automatically, as the diagnosis is the same as for the surgical claim.

    While it is true that the provider, in item number 2, is doing a post-op evaluation of the left eye, he is actually spending the bulk of his time evaluating the right eye and deciding to move ahead with surgery.

    My question, thus, is this a typical practice for a provider to perform both the post-op visit and the evaluation of the other eye at the same time? And if so, does the provider typically receive reimbursement for the portion of the exam that is unrelated to the post-op follow up?

    Thanks for any help.

  2. #2
    Default
    Try S/p cataract surg code (V code)for one eye and pre-op exam along with caratact for other eye
    diagnosis (v72.83 and cataract)

  3. #3
    Default
    If the diagnosis of cataracts was documented in both eyes when the patient presented for the visit prior to surgery on the first eye, the insurance company will not pay for the diagnosis to be made again in post op of the 1st eye.
    Sharon

  4. #4
    Default
    Quote Originally Posted by lyon0023 View Post
    Good Morning,

    I am trying to determine what the typical behavior and expectation for reimbursement is on E&M services provided by ophthalmologists in the post-op period for a cataract surgery.

    Here's the general scenario:

    1. The provider performs surgery to remove a cataract in one eye, perhaps the left to start.

    2. The provider sees the patient in the post-op period to check the left eye, however, also checks the right eye, and decides to proceed with cataract surgery for the right eye. The provider schedules the patient a time for the next surgery.

    Currently, the payor I work for denies the claim for item number 2, as part of the global for the cataract surgery. Even when the 24 modifier is appended to the claim, it denies through system automatically, as the diagnosis is the same as for the surgical claim.

    While it is true that the provider, in item number 2, is doing a post-op evaluation of the left eye, he is actually spending the bulk of his time evaluating the right eye and deciding to move ahead with surgery.

    My question, thus, is this a typical practice for a provider to perform both the post-op visit and the evaluation of the other eye at the same time? And if so, does the provider typically receive reimbursement for the portion of the exam that is unrelated to the post-op follow up?

    Thanks for any help.

    We don't bill the visit at all because our doctor's examine both eye's on the initial visit and decides to perform surgery on both eyes that day. Even though he is doing the pre-op and admit charges for the seperate eye on the follow up visit, he still made the decision for surgery on the initial visit, therefore it is considered global. This is how our billing is but i'm sure that everyone's is different.

  5. #5
    Location
    Peninsula Professional Coders, Newport News, VA
    Posts
    3
    Default Cataract Global Period Billing
    A claim for services cataract-related will not be paid during a cataract global period. They look at the fact that both eyes were determined to have cataracts when the first surgery was decided upon. The surgeon decides which eye he/she feels is most visually impaired to operate on first. The second eye truly has been evaluated when the first surgery was decided upon. I've yet to see any payer reimburse for it.

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