67228Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; photocoagulation (laser or xenon arc). Coding PRP in Two Eyes
You do not need a different diagnosis for the second eye procedure, just modifier -79. With laser procedures, the diagnosis often is the same for both eyes. For example, when panretinal laser (67228) or panretinal photocoag-ulation (PRP) is performed on one eye for proliferative diabetic retinopathy (362.02, Diabetic retinopathy; proliferative diabetic retinopathy) and the other eye needs treatment within 90 days, the second eye's treatment is almost always for the same diagnosis. If the first treatment is in the left eye, you should report 67228-LT. For the second treatment, code 67228-79-RT.
The eye modifier is essential in the above scenario. Without it, the payer would see the same procedure code and the same diagnosis code and, without the eye modifiers, would assume you are billing twice in error for the same eye. Modifier -79 would seem completely inappropriate without the eye modifiers.
Decision for Surgery
If the ophthalmologist sees the patient postoperatively for a panretinal photocoagulation (67228) for the left eye and discovers new lesions that require the same procedure in the right eye, he or she might be able to bill an office visit (99211-99215) in addition to the laser treatment. The visit would have to be billed with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to show that it is unrelated to the postoperative care for the left eye. In addition, you should append modifier -57 (Decision for surgery) to the E/M code to show that the visit is not included in the preoperative period for the right eye because during the visit the ophthalmologist initially decided the surgery was necessary.
Reporting Cataract Surgery
When coding for cataract surgery (66830-66986) in the postoperative period using the -LT and -RT modifiers, you should remember that the guidelines are somewhat different from the rules for lasers. Most carriers maintain that you cannot bill a visit within the cataract surgery postoperative period for the decision to perform a similar procedure on the fellow eye. The payers believe that if you perform the second eye surgery within 90 days of the first, you had already decided that the second eye should be treated when you decided to perform surgery on the first eye, says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses.
Unlike the lasers for macular degeneration, retinal defects and other problems, cataract removal is an elective procedure that can be performed at any time. That makes the condition different from an exacerbation of an underlying disease process that necessitates a nonelective procedure. Consequently, modifier -57 may not suffice when seeking reimbursement for an E/M visit performed within the cataract surgery's global period.
You will be paid for the cataract surgery, however. And you should use the eye modifier to do so. You should report the procedure with modifier -79 and the appropriate eye modifier if done within the global period of the first cataract surgery. Assuming you billed for the first procedure with the appropriate eye modifier, you should receive the full Medicare fee schedule amount for the second procedure.
Using Modifier -24
Modifier -24 is necessary to show that an office visit in a postoperative period is unrelated to the surgery. You do not need to use the eye modifiers (-LT and -RT) when reporting a procedure with modifier -24 appended.
For example, during the cataract surgery postoperative period for the left eye, the ophthalmologist notices that the right eye which had cataract surgery with an intraocular lens (IOL) a year ago has developed a significantly cloudy posterior capsule that requires surgery. You should report the office visit (99211-99215) with modifiers -24 and -57. Append modifier -79 and modifier -RT to the surgical procedure code. You should also use the diagnosis code 366.53 (Cataract; after cataract; after-cataract, obscuring vision) to show medical necessity for the procedure.
Similarly, if the patient complains of itchiness in the fellow eye during the postoperative period for cataract surgery, you should bill an office visit (99211-99215) with modifier -24 appended, reporting diagnosis code 372.00 (Disorders of conjunctiva; acute conjunctivitis; acute conjunctivitis, unspecified). You still need modifier -24, even if the visit is on a different eye and with a different diagnosis, Duran says.
In a laser example, the ophthalmologist performs PRP (67228) on the right eye. Within the 90-day postoperative period, he or she has to evaluate the left eye because the patient complains his vision has become blurry. The physician discovers that the left eye now has bleeding vessels (362.81), which must be treated. For the office visit during which the ophthalmologist assesses the second eye, you might have to fight for payment, Roberts says. Although most Medicare carriers will recognize modifier -24 appended to the office visit code and will process payment, others consider any service performed within the 90-day global period for 67228 to be included in the reimbursement for the PRP, regardless of modifiers and diagnosis codes submitted for the E/M service. You should be prepared to submit a copy of the medical record to prove this visit was unrelated.
Bill the right eye surgery with modifier -RT (67228-RT) and the interval visit at which you assess the left eye with modifier -24. If you treat the left eye on the same day as the E/M visit or the next day, you should append modifier -57 to the office visit code. For the surgery on the left eye, you should bill 67228-79-LT.
Coding the Diagnosis
Some conditions are likely associated with both eyes, whereas others are more likely to be associated with only one. In the case of an underlying disease, a diagnosis code could refer to both eyes, as with glaucoma (365.xx). In the case of a trauma or a problem such as chalazion (373.2) or retinal detachment (361.x), the diagnosis code would probably refer to only one eye.
Use Modifiers for Tests as Well
For some testing procedure codes, as with laser and cataract removal, eye modifiers are essential for proper reimbursement.
For example, you should append 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) with -LT and -RT because Medicare pays for the technical component bilaterally and the professional component unilaterally. Reporting 76519 includes a professional component (modifier -26) and a technical component (modifier -TC). The eye modifier should always be used with 76519 in case you bill for the professional component of the second eye when the lens power is selected for cataract surgery on the fellow eye. For the second eye, bill 76519-26 and the other eye modifier.
Depending on the insurance carrier, you may be required to use modifiers -LT and -RT for extended ophthalmoscopy (92225, Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial;and 92226, subsequent), indocyanine green (92240, Indocyanine-green angiography [includes multiframe imaging] with interpretation and report), fluorescein angiography (92235, Fluorescein angiography [includes multiframe imaging] with interpretation and report), and optic disk scanning (92135, Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral), Duran says.
Also, append modifiers -LT and -RT for any testing service if the insurance carrier does not recognize modifier -50 (Bilateral procedure), Duran says. Then you have to use two lines with modifier -LT appended to the proper procedure code on one, and the same code with modifier -RT on the other.
If the payer recognizes a CPT code as a unilateral (payable per eye) procedure and accepts modifier -50 to show that it was performed bilaterally such as fluorescein angiography when billing on one line, such as 92235-50, the documentation must show that the diagnosis applies to both eyes. Otherwise, you are submitting a fraudulent claim, Duran says. If the diagnosis is different, you should submit the same procedure code on separate lines with the documented diagnosis code attached to each line.
Use Eyelid Modifiers
Occasionally, the eyelid modifiers (-E1--E4) are preferable to modifiers -RT and -LT. For example, the ophthalmologist performs 67904 (Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) on both upper lids. When performed bilaterally, you should use 67904-50 for Medicare, not the eye modifiers or the eyelid modifiers. But for other payers, you should use the eyelid modifiers for example, 67904-E1 and 67904-E3 for both upper lids. The eyelid modifiers are more specific than either 67904-50 or 67904-RT and 67904-LT.
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