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Young Ophthalmologists
Common Coding Errors

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To help you navigate the often-confusing world of coding, we’ve compiled several of the most common coding errors and the correct way to code these procedures. Topics include: suture removal, benign and malignant skin lesion removal, complications during the global period, exam before second eye surgery, two providers same day and A-scan coding 76519 and 92136.

Suture Removal
Other than CPT code 15850 Removal of sutures under anesthesia (other than local), same surgeon or CPT code 15851 Removal of sutures under anesthesia (other than local), other surgeon, suture removal is never separately payable. It is part of the global surgical fee or part of the evaluation and management or eye code billed if you were not the surgeon, or if the patient is out of the global period. It is never a corneal foreign body.

Laser suture lysis is considered suture removal. It is inappropriate to code 66250 Revision or repair of operative wound for this service.

Benign and Malignant Skin Lesion Removal
When coding from the integumentary section of CPT for either benign or malignant lesions, keep these points in mind:

Codes involved:
11440:  Excision benign lesion, face, eyelids, 0.5 cm or less
11441:  0.6 cm to 1.0 cm
11640:  Excision malignant lesion, face, eyelids, 0.5 cm or less
11641:  0.6 cm to 1.0 cm

Site of service differential — Each code is a site-of-service differential. Payment to the physician is greater when performed in the office instead of in an ambulatory surgical center (ASC) or hospital.

Global periods — Each procedure has a 10-day global period.

ASC coverage — Each procedure will be payable in an ASC as of January 2008.

Payment — Each procedure is payable per session. Not per lesion, lid or eye.

It is not appropriate to append:

  • Modifier 59 indicating a separate site; or
  • Modifier 50 indicating bilateral; or
  • Modifiers RT or LT indicating bilateral; or
  • Modifiers E1–E4 indicating lid location.

Complications During the Global Period
When a complication develops during the global period, one of the following three modifiers is appropriate to use:

Modifier 58: Staged or related procedure or service by the same physician during the postoperative period

There are three definitions for use:

  1. Performance of a procedure was determined pre-operatively,
  2. The procedure was more extensive than the original procedure,
  3. Therapy performed following a diagnostic surgical procedure.

Examples:

  1. A patient underwent 66761 iridotomy, now needs 65855 SLT within the 90-day global period. The surgeon indicated the possibility in the medical record.
  2. During the 90-day postoperative period of 67105, 67107 repair of retinal detachment; scleral buckling is performed on the same eye (CPT code 67107-58-eye modifier).
  3. Patient presents during the postop period of a trabeculectomy. A therapeutic injection of 5FU is given (CPT code 68200-58-eye modifier and J9190 for Fluorouracil).

Modifier 78: Return to the operating room (or laser suite) for a related procedure during the global period

Example: Cataract surgery right eye with IOL is performed. During the 90-day postoperative period, a YAG capsulotomy is performed in the right eye (CPT code 66821-78-RT).

Modifier 79: Unrelated procedure or service by the same physician during the postoperative period

Example: Cataract surgery is performed in the left eye during the global period of cataract surgery in the right eye (CPT code 66984-79-LT).

Exam Before Second Eye Surgery
A patient is evaluated and found to have bilateral cataracts at the initial visit. The patient is scheduled for surgery, has the right cataract removed and is seen postoperatively. At the second postop visit, the patient wants to schedule the surgery for the left eye. Can this be billed as an E&M code visit? If so, what documentation is needed? Or can we only bill for the A-scan, second eye?

In some instances, practices bill for an exam related to a second cataract surgery, which is performed during the first surgery’s postoperative period by the same ophthalmologist or ophthalmology group responsible for that surgery. Such exams are billed on the basis that this visit is for clearance/decision for surgery on the second eye.

However, in this situation, since the visit is primarily for postoperative follow-up of the first surgery and only a brief exam of the second eye, separate payment to the same ophthalmologist (or group) would not typically be allowed for the visit.

The following indications would support coverage for a separate visit prior to second cataract surgery:

  • Examination more than 90 days after the first procedure,
  • New symptoms in the second eye,
  • Significant change in health requiring new evaluation prior to proceeding with surgery.

So, unless you truly feel this qualifies for a separate visit, bill the A-scan only. In those situations where a second exam is appropriate to bill, append modifier 24 to the visit. It’s best to have separate detailed documentation from the postop portion of the visit, as it is likely that Medicare will deny the visit, even with the 24 modifier (because the diagnosis is the same or similar, 366.XX). If this happens, you will have to appeal with notes.

Exam codes are typically bilateral, not unilateral.

Two Providers, Same Day
Medicare generally pays one E&M service per day per specialty. Unfortunately, Medicare does not typically recognize specialists within the same profession. If your patient is going to see both providers on the same day, for the same problem, the doctors may combine their services and bill one code. While two appointments scheduled on the same day may be convenient for the patient and the physicians, they are not always covered by the payer.

Bottom line: Unless it’s an emergency, do not schedule two separate exams on the same date of service.

A-Scan Coding 76519 and 92136
These two tests are unique in the respect that the technical component (actual scan) is bilateral, while the professional component (calculation) is unilateral.

For Medicare and other federal payers:

  • 1st eye: Measurement for both eyes, surgery on the right eye
    • Bill as: 76519-RT Ophthalmic biometry by ultrasound echography, with intraocular lens power calculation (or) 92136-RT Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation. This includes payment for the global technical component and the professional component for the right eye.
  • Two months later cataract surgery is performed on the left eye.
    • Bill as: 76519-26-LT or 92136-26-LT.
    • Payment is for the professional component of the left eye.
  • If surgery on the right eye was performed by a physician outside your group, but you are now performing surgery on the left eye, code as follows:
    • Bill as: 76519-TC-LT or 92136-TC-LT and 76519-26-LT or 92136-26-LT.
    • Payment is for the technical component of the left eye and for the professional component of the left eye.

Non-Medicare payers:

The technical or professional component is generally not recognized; the full allowable per eye will be paid.

  • 1st eye: Measurement of both eyes, surgery on the right eye
    • Bill as: 76519-RT or 92136-RT.
  • Two months later, cataract surgery is performed on the left eye.
    • Bill as: 76519-LT or 92136-LT

The Correct Coding Initiative bundles 76519 and 92136 when billed on the same day. If both were billed, the lower allowable of the two codes would be paid.

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About the author: John Haley, MD, OCS; Stephen Kamenetzky, MD, OCS; Donna Marks, CPC, CCS-P, OCS; and Sue Vicchrilli, COT, OCS, Academy coding executive.