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  • Coding Competency Challenge

    Coding Knowledge
    Question: A few of our cataract patients who do not want a premium IOL have requested their natural lenses be removed with the laser. Which of the following is true about the physician and/or facility charge for the use of the laser? 
    1. The practice must absorb the charge as it is not billable.
    2. The insurance must cover the cost if it is preauthorized.
    3. The patient must cover the charge since this is an additional service.
    4. The facility must charge the insurance using an add-on code.
    Answer: A. No matter what technique the surgeon uses to remove the natural lens, bill only 66984 or 66982 if the surgery qualifies as complex. There is nothing additional to submit to the payer or the patient. 

    Vision vs. Medical 
    Question: A patient appears for a six-month follow-up for glaucoma suspect. A visual field was ordered at the patient’s last dilated fundus exam. Now the patient has broken glasses, needs a new prescription and has commercial medical insurance and a separate vision plan. The office participates with both plans and the patient is eligible for both medical and routine services. The medical copay is $20, with 30% co-insurance for testing services. The vision copay is $10. Which of the following is not an appropriate billing option for this scenario?
    1. Provide and bill out as a routine eye exam and bring the patient back another day for the medical exam. Collect the $10 copayment. 
    2. Address the medical need as requested at the last visit as soon as possible and bring the patient back for the routine eye exam. Collect the $20 copayment and 30% coinsurance for the test.
    3. Provide a routine eye exam and perform the visual field. Collect the $10 copay and bill to the vision plan and 30% coinsurance and bill the medical plan for the test.
    4. Provide both services on the same day and bill the medical exam and the visual field to the medical insurance and the routine exam to the vision insurance. Collect both copays and the 30% coinsurance for the test.  
    Answer: D. The bottom line is that you cannot bill one exam performed on the same day to both medical and vision. Make sure the patient is aware of any out-of-pocket expenses. 

    Case example: A patient who had cataract surgery in the right eye two months ago calls complaining of flashes of light and floaters in the left eye. A retina specialist in the same group as the cataract surgeon examines the patient. 
    Diagnosis: Retinal horseshoe tear, left eye
    Plan: Diode laser today. CPT code 67145 - Prophylaxis of retinal detachment (e.g., retinal break, lattice degeneration) without drainage, 1 or more sessions; photocoagulation (laser or xenon arc) How should you code this case? 
    1. No exam + 67145 -79 -RT
    2. Exam and modifier -25 + 67145 -79 -RT
    3. Exam and modifier -57 + 67145 -79 -RT
    4. Exam and -24 modifier + 67145 -79 -RT
    Answer: A. The exam could be billable as flashes and floaters are unrelated to the surgery since in the fellow eye. Modifier -24 would be necessary because physicians are in the same group practice and the exam is during the global period. However, modifier -25 would be required, but is not appropriate as the exam was performed solely to confirm the need for the minor procedure, 67145 has a 10-day global period. Therefore, the exam is not billable. Modifier -79 is necessary as the laser procedure is unrelated to the cataract surgery. 

    Testing services
    Case example: A patient with Medicare Part B presented with complaints of decreased vision OD>OS. They noticed over the last few months that signs are getting harder to read and small print is also difficult. VF8R was provided for the right eye. Best corrected visual acuity in the right eye is 20/50 and in the left eye it is 20/40. 
    Diagnosis: 3+ NS, 3+ PSC right eye and white cataract, hypermature left eye
    Plan: Cataract surgery, right eye first. The surgeon orders IOLMaster in both eyes to be performed the same day. 

    The technician attempts to perform the IOLMaster however, there is difficulty in producing results, so an Ascan is used. The surgeon is now able to select the most appropriate lens. How should the biometry be submitted?
    1. 76519
    2. 76519 -26
    3. 92136 -TC + 76519
    4. 92136
    Answer: A. Bill the test that provides the calculation used to determine lens power. 76519 and 92136 are mutually exclusive. Medicare Part B is unique in that it allows: 
    • One global technical component (-TC) for measuring both eyes
    • One professional component (-26) for each eye
    Commercial payers may not recognize -TC and -26 components. Even among Medicare, there are variances in billing.

    Major/Minor Procedures
    Question: When a surgery whose definition includes “one or more sessions” language is repeated during the global period for the same reason on the same eye, how should you bill? 
    1. Not billable since the initial payment is for the entire global period.
    2. Bill to the patient after having them sign an advance beneficiary notice (ABN).
    3. Bill to the insurance with modifier -58 as a staged or related procedure.
    4. Bill to the insurance with modifier -78 as the surgery is unplanned but related.
    Examples of surgeries with one or more sessions language:
    • 67208 — Destruction of localized lesion of retina (e.g., macular edema, tumors), one or more sessions; cryotherapy, diathermy
    • 67210 — Destruction of localized lesion of retina (e.g., macular edema, tumors), one or more sessions; photocoagulation
    • 67218 — Destruction of localized lesion of retina (e.g., macular edema, tumors), one or more sessions; radiation by implantation of source (includes removal of source)
    • 67220 — Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions
    • 67229 — Treatment of extensive or progressive retinopathy, one or more sessions
    Answer: A. The initial payment is for the entire global period, no matter how many additional times the surgery must be performed. 

    How did you do? Consider these Academy coding and reimbursement resources to help fill in the gaps:
    Coding Topics

    Coding News and Expert Advice

    Coding Updates and Resources

    Codequest Coding Courses

    2023 Fundamentals of Ophthalmic Coding

    Academy Private Consultation Services

    No sweat? Consider taking the OCS exam. Find more information at Ophthalmic Coding Specialist (OCS) Exam.