In coding, certain mistakes are made time and again. Such errors were put in the spotlight at an Annual Meeting session presented by John Haley, MD, OCS, Stephen Kamenetzky, MD, OCS, Donna Marks, CPS, CCS-P, OCS, and Sue Vicchrilli, COT, OCS.
Exam Before Second Surgery
Suppose a patient has had one cataract operation and, during the postop period, returns to the same ophthalmologist or ophthalmology group for an exam prior to the second cataract. Can this be billed on the basis that it is for clearance/decision for surgery on the second eye? Tread carefully. The visit is primarily for postop follow-up of the first surgery and only a brief exam of the second eye. Therefore, separate payment to the same ophthalmologist (or group) would not typically be allowed for the visit.
However, the following indications would support coverage for a separate visit prior to second cataract surgery: Exam more than 90 days after the first procedure; new symptoms in the second eye; or significant change in health requiring new evaluation prior to proceeding with surgery.
Unless you truly feel this qualifies for a separate visit, bill the A-scan only. In those situations where it is appropriate to bill the second exam, append modifier –24 to the visit. It’s best to have separate detailed documentation from the postop portion of the visit. Even with modifier –24, Medicare is likely to deny the visit—because the diagnosis is the same or similar, 366.XX—and you’ll need those notes for your appeal.
Two Providers on Same Day
Medicare generally pays one E&M service per day per specialty, and it doesn’t typically recognize specialists within the same profession. If a patient is going to see two providers on the same day, for the same problem, the doctors may combine their services and bill one code. While two appointments on the same day may be easiest for all parties, they’re not always covered by the payer.
The bottom line: Unless an emergency, do not schedule two separate exams on the same date of service.
A-Scan Coding: 76519, 92136
These two tests are unique in that the technical component (actual scan) is bilateral and the professional component (calculation) is unilateral.
Medicare and other federal payers. Suppose a patient undergoes measurements for both eyes and surgery only in his right eye. Bill this as 76519–RT Ophthalmic biometry by ultrasound echography, A-scan; with IOL power calculation or 92136–RT Ophthalmic biometry by partial coherence interferometry with IOL power calculation. This bills for the global technical component and, for the right eye, the professional component.
Two months later, he returns for cataract surgery on his left eye. Just bill for the professional component of the left eye: 76519–26–LT or 92136–26–LT.
Suppose, however, the initial surgery had been performed by another physician (outside your group) and you now perform surgery on the left eye. You still bill either 76519–26–LT or 92136–26–LT for the professional component of the left eye, but now you also bill 76519–TC–LT or 92136–TC–LT for the technical component.
Non-Medicare payers. Generally, these payers do not recognize the technical and professional components and will pay the full allowable for each eye. If a patient undergoes measurements for both eyes and surgery in his right eye, you can bill either 76519–RT or 92136–RT. And when he returns two months later for surgery on the left eye, you bill either 76519–LT or 92136–LT.