The American Academy of Ophthalmic Executives has lately received a host of interesting questions inquiring about different coding-related matters. Below is a second installment of the standouts. For information about courses, online tools and products related to coding or to contact AAOE staff directly, visit the AAOE’s new website.
|What is the appropriate way to bill for a surgical procedure performed bilaterally during the same operative session?
||Effective April 1 of this year, updates to the Unit of Service of Medically Unlikely Edits implemented a change. Instead of submitting the surgical code on a two-line item with modifiers –RT and –LT, the surgical code should be appended with modifier –50, with a “1” in the unit field. Failure to submit claims in this matter has resulted in payment denial.
Example: Bilateral blepharoplasties are performed. Submit 15823–50 Blepharoplasty, upper eyelid; with excessive skin weighting down lid, with “1” in the unit field. Double your charge.
The Multiple Procedure Payment Reduction rule still applies. The payer will allow 100 percent of the allowable of the first procedure and 50 percent of the allowable for the second (other eye).
|During the global period, a postoperative cataract patient presents with the complaint of flashes/floaters. Can we bill an exam as unrelated to the surgery?
||It all depends on whether it is actually related or unrelated to the surgery. If related, it is part of postop care and not separately billable.
If you are going to bill, you need to clearly indicate in your chart note why the diagnosis is unrelated to the surgery. Submit the appropriate level of exam with modifier –24, indicating an office visit unrelated to the surgery.
The diagnosis code should be 379.24 Floaters of the vitreous. There is not a code for flashes.
The ICD-10 equivalent of 379.24 is H43.39. When a dash (–) is present in the ICD-10 code, there is an additional digit to be added. Oftentimes, the additional digit is for the right, left or bilateral sides of the body.
|Where can I find a list of postoperative periods for all surgical procedures? Does this vary by payer?
||For Medicare Part B, a list of postoperative periods for all surgical procedures can be found on the CMS website under the Physician Fee Schedule page. Look for the relative value unit files, and download the Excel file titled PPRVU. In column U, you will find the postoperative days. Some codes have an XXX in the postoperative day’s column. These are “add” codes, which follow the same postoperative days as the primary code they are billed with. Note: The PPRVU file contains all codes for medicine.
Postoperative days do vary by payer. For example, the CPT code 65855 Trabeculoplasty has a 10-day global period for Medicare, but some commercial payers still recognize the 90-day global period. It’s best to check the global period with each payer prior to scheduling surgery.
|When probing and insertion of a tube is performed during the same surgical session, are both payable?
||There is one code that describes both services: 68815 Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent.
|If the insurance company denies payment for Category III code 0192T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach, can we submit a correct claim with CPT code 66170 Trabeculectomy?
||No. Prior to surgery for the Medicare Part B patient, you should obtain an Advance Beneficiary Notice (ABN) and submit 0192T–GA, which informs Medicare Part B that an ABN is on file; for commercial payers, it’s best to inform the patient in writing that they may be responsible for payment.
Submitting a Level 1 CPT code when there is a specific Category III code would be considered a fraudulent claim submission.
|When payment for a test is inherently bilateral and we only test one eye, should we submit with modifier –52 indicating a reduced service or eye modifier(s) –RT/–LT?
||No. A modifier is not required. With inherently bilateral tests, the payer recognizes that the test is often for one or both eyes. Payment is the same if one or both eyes were tested.
|Probing the left lacrimal duct didn’t resolve the problem and the surgeon performed a snip procedure a week later. How should this be coded?
||Submit CPT code 68840–78–LT (Probing of lacrimal canaliculi, with or without irrigation) if performed within the 10-day global period for the first probing procedure 68815 (Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent). Modifier –78 indicates performance of an unplanned procedure performed in the operating room or office procedure room. Payment is 80 percent of the allowable, as an additional 10 days is not added to the global period.
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About the author: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE's Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series.