Billing and coding may not be enjoyable, but it’s a necessary evil of practicing medicine. Whether you oversee this process yourself or you have a dedicated staff member, it’s important to know certain rules and reasoning to get the most out of your time and effort. In this column I provide answers to some of the questions I’m asked most frequently.
QUESTION: In our rural community, primary care physicians sometimes ask us to provide the interpretation and report on photos taken in the primary care physician’s office for patients with known diabetic retinopathy in order to meet their Healthcare Effectiveness Data and Information Set requirements. Is this coded as 92250 Fundus photography, appended with modifier -26?
ANSWER: This is an example of telehealth. For patients with known retinopathy:
- 92228 -26, billed by the ophthalmologist $21.06
- 92228 -TC, billed by the PCP $13.78
- Do not report 92250 -26 for telemedicine $22.51
QUESTION: Suppose the doctor performs surgery with CPT language “one or more sessions” and must repeat the procedure during the 90-day global period. Is it possible to have the patient pay for the second procedure after having him or her sign an Advance Beneficiary Notice (ABN)?
ANSWER: The Current Procedural Terminology (CPT) codes with “one or more sessions” in their descriptor are these:
- 67208 Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; cryotherapy, diathermy;
- 67210 Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; photocoagulation;
- 67220 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), one or more sessions.
Under no circumstance should you charge the patient as described. Medicare might interpret this as an attempt to commit fraud and as inappropriate use of an ABN. Medicare Part B payment is for the entire 90-day period no matter how many additional times the physician must perform the procedure.
QUESTION: In a group practice, the comprehensive ophthalmologist saw a patient for flashes and floaters, then referred the patient to the same group practice’s retina surgeon. Later that day, the retina specialist examined the patient, performed extended ophthalmoscopy, and surgically repaired a retinal detachment. What is billable in this scenario?
ANSWER: What was the comprehensive ophthalmologist’s diagnosis? If both physicians used the same diagnosis, only one of them can submit a claim. In 2013, the National Correct Coding Initiative bundled extended ophthalmoscopy with surgery when performed the same day. The practice should submit the appropriate level of Evaluation and Management or Eye visit code with modifier -57 to indicate that this was the office visit to determine the need for surgery and the surgery itself.
QUESTION: Can we unbundle CPT codes 67036 Pars plana vitrectomy and 67145 Prophylaxis of retinal detachment; photocoagulation with modifier -59 when performed simultaneously with or without tear?
ANSWER: CPT code 67145 has been bundled with 67036 since 1996. It is inappropriate to unbundle due to treatment of contiguous structures. Instead, bill CPT code 67036 Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation, as it has the higher allowable. If both codes are submitted, the payer has the option to accept the lower allowable code.
QUESTION: Our administrator told us to bill a sample medication as $0.01 along with the injection. Shouldn’t the charge be zero because we used a sample?
ANSWER: If your clearinghouse won’t accept a zero charge it’s best not to submit a claim for the sample medication at all.
QUESTION: Because payment for 92235 Fundus photography, 92240 ICG and 92242 Combined FA and ICG, is now bilateral instead of unilateral, should we append either modifier -RT or -LT, or modifier -52 to show reduced services?
ANSWER: Unless the specific payer states to do so in writing, the answer is no. No modifier is necessary. These codes have the same allowable whether one or both eyes are tested and include the language “unilateral or bilateral.”
QUESTION: We have a patient with bilateral wet agerelated macular degeneration with active choroidal neovascularization. On a recent visit we injected only the patient’s left eye. Do we append the bilateral diagnosis to the injection?
ANSWER: No. This is cause for a denial with many payers. If the CPT code requires modifiers -RT or -LT, and the ICD-10 code has laterality, be sure bilateral is not reflected in the ICD-10 code selection. If the injection is in the left eye, use H35.3221 Exudative age-related macular degeneration, left eye, with active choroidal neovascularization.
QUESTION: I performed bilateral repair of a retinal tear (CPT code 67145 Repair of retinal tear) on a Medicare patient on the same day. The first claim I submitted was 67145 -RT, 67145 -LT. When the payer denied it, I resubmitted 67145 -RT, 67145 -LT-51. The payer also denied the second claim. What is the best way to submit for reimbursement?
ANSWER: As of April 2013, Medicare Part B requires all bilateral surgical procedures to be submitted as a single line 67145 -50 with a “1” in the unit field and double the charge. Medicare will pay 150% of the allowable. By not submitting the payment correctly, as you’ve experienced, you may be denied payment, or payment may be 100% of the allowable rather than the correct 150%. Commercial payers will vary in their requirements. Some may prefer two lines with -RT and -LT. No need to append modifier -51; most payers’ systems are sophisticated enough to recognize multiple procedures in the same setting.
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QUESTION: What modifiers are required when performing both CPT code 67210 Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; photocoagulation, and CPT code 67028 Intravitreal injection in the same right eye?
ANSWER: As of April 1, there are no bundling edits with these two CPT codes. Submit 67210 -RT and 67028 -RT. Payment will be 100% for the first procedure, and the second procedure payment will be reduced by 50% due to multiple procedure guidelines.
QUESTION: Is there a postoperative period for laser therapy and treatment with injections? We have a patient who had laser on March 1 and then an injection on March 25.
ANSWER: All surgical procedures have a global period of either 0, 10, or 90 days of postoperative care. Medicaid payers also recognize a 60-day global period on many major procedures. When the injection is performed during the global period, append modifier -58 and the eye modifier to the injection code.