Remember the pirate’s often-lost wooden eye in Pirates of the Caribbean? Or Tom Cruise’s eye transplant in Minority Report? Movies showing eye injuries intrigue us. Although it is a challenge to code these incidents, an even greater challenge lies in correctly coding the ophthalmic procedures we see daily. Our focus is to begin highlighting key points in coding the services most frequently performed in ophthalmology.
A-Scan Ultrasound for Intraocular Lens Calculations
CPT® codes 76519 Ophthalmic biometry by ultrasound echography A-scan; with intraocular lens power calculation and 92136 Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation
Report 92136 for use of the IOL Master, which allows measurements of eye length and surface curvature, necessary for cataract surgery.
Medicare rules differ from non-Medicare payers. For Medicare, these codes have one global technical component (modifier TC Technical component) and a professional component (modifier 26 Professional component) for each eye. Because non-Medicare payers typically do not recognize these modifiers, only the RT Right side or LT Left side modifiers should be appended to 76519 or 92136.
Argon Laser Trabeculoplasty (ALT)
CPT code 65855 Trabeculoplasty by laser surgery, one or more sessions (defined treatment series)
Medicare has assigned a 10-day global period to this code for either an Argon laser trabeculoplasty (ALT) or selective laser Trabeculoplasty (SLT). This means that when a separately identifiable exam is performed the same day, modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service should be appended to the appropriate level of exam.
Because non-Medicare payers still recognize a 90-day global period for 65855, modifier 57 Decision for surgery should be appended to the E&M code, describing the exam that determines the need for surgery when the laser is performed on the same day. Beginning January 2008, this procedure became payable in an ASC.
Benign Skin Lesions
Medicare and non-Medicare payers will cover benign skin lesion removal with appropriate documentation. The chief complaint should contain words such as red, increasing in size, oozing and/or itching. A photo for documentation purposes is helpful.
As with any procedure that may be considered cosmetic, it is best to obtain an Advance Beneficiary Notice (ABN) from the patient. Append modifier GA Waiver of liability statement on file to the claim, indicating an ABN is on file.
Codes in the Integumentary section of CPT have a zero-day global period.
CPT code 15822 Blepharoplasty, upper eyelid and 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid
Most Medicare payers have a Local Coverage Determination (LCD) indicating specific preop documentation requirements to distinguish cosmetic vs. functional blepharoplasty. CPT code 15822 is typically considered cosmetic. By appending modifier GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit, offices indicate as such.
CPT code 15823 is typically submitted for functional claims. One key component often missing in chart documentation for functional claims is the lack of a visual complaint from the patient. Too often the chart might state, “Patient complains of excessive baggy upper lid skin,” which does not provide medical justification for a functional claim.
These procedures have a 90-day global period.
CPT code 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)
Extracapsular cataract removal is the number one procedure performed in ASCs. Contrary to what many physicians and coders think, there isn’t a national policy with a visual acuity requirement. Coverage varies by payer. The best documentation indicates the impact the reduced vision has on the patient’s daily living activities.
CPT code 66984 has a 90-day global period.
Complex Cataract Extraction
CPT code 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage
It’s important to note that this CPT code is not for:
- Complications that occur during surgery;
- Vitrectomy performed at the time of surgery;
- Piggyback or multi-focal IOLs;
- Specific viscoelastic like Healon 5 or Healon GV;
- Complex cases that take longer than usual;
- Diagnosis of floppy iris syndrome or use of Shugarcaine intraoperatively; or
- Extraordinary services performed in routine cataract surgery.
Note: Payers who have coverage policies also allow coverage for mature white cataract requiring dye for capsulorrhexis, which is the making of a continuous circular tear in the anterior capsule during cataract surgery to allow evacuation by pressure of the nucleus of the lens.
CPT code 66982 has a 90-day global period.
CPT code 92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report
This test has unilateral payment, which means 100 percent of the allowable fee is payable per eye, when medically indicated. It is inappropriate to submit a claim for the eye that does not have pathology. Claims may be submitted as a single line item (e.g., 92235-50) or a two-line item with the RT and LT modifiers (e.g., 92235-RT, 92235-LT), depending on payer preference. Cost of the dye is not separately payable.
CPT code 92250 Fundus photography with interpretation and report
This code is inherently bilateral. Payment is the same whether one or both eyes are photographed. The Correct Coding Initiative (CCI) bundles fundus photography with CPT code 92135 Scanning computerized ophthalmic diagnostic imaging, posterior segment, (eg, scanning laser) with interpretation and report, unilateral.
CPT code 65222 Removal of foreign body, external eye; corneal, with slit lamp
This code has a zero-day global period, which means that when the physician sees the patient a few days later, it is a billable exam. The procedure is payable per eye, not per foreign body. And, in the event a rust ring develops, 65222 is the appropriate code to use again.
For more procedures, check back next month, when we resume our discussion with keratoplasty.
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About the author: This article was adapted from a version that originally appeared in the February 2009 issue of Coding Bulletin. It was written by AAOE coding executive Sue Vicchrilli, COT, OCS, and Academy coding specialist Kim Ross, CPC, OCS.