Cataract Surgery Billing and Coding Tips

June is Cataract Awareness Month and we’re giving you our top billing and coding tips for cataract surgery. Cataracts are the leading cause of vision loss in the United States, affecting over 22 million people. To reduce the risk of an audit and get paid correctly and in a timely manner, it’s imperative that your documentation is correct.

One of the biggest mistakes when billing for cataract surgery is billing for the same eye twice. It may sound obvious, but many practices have made this mistake. When billing the second eye in a post op period, append modifier -79 with the eye modifier (RT, LT). Always double check the claim prior to submission to verify the correct eye. Per Medicare Local Coverage Determinations (LCDs), the patient must fill out the VF-14, a commonly referenced scale of determining the visual effect of cataracts on a patient’s activity of daily living. Questions include:

  • Driving during the day/night

  • Reading small print on medicine bottles, telephone book, food labels

  • Reading a newspaper or book

  • Reading large print book or large print newspaper or numbers on a telephone

  • Recognizing people when they are close to you

  • Seeing steps, stairs, or curbs

  • Reading traffic signs, street signs, or store signs

  • Doing fine handiwork, sewing, knitting, crocheting, or carpentry

  • Filling out forms

  • Playing games such as bingo, dominoes, and cards

  • Taking part in sports like bowling, tennis, golf

  • Cooking

  • Watching television

Other documentation you must include in the chart note: evidence of the patient’s preoperative best-corrected visual acuity; record of visual distortion or complaints of glare associated with functional impairment; documentation supporting visual acuity improvement with the removal of the cataract; a signed operative report; and, documentation showing the patient understands the risks, benefits, and expected outcomes of surgery, and most importantly, desires cataract surgery.

  • 66984: Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (i.e. irrigation and aspiration or phacoemulsification); also known as ECCE. This is the standard method of cataract surgery where the natural lens (cataract) is removed along with the anterior shell. The posterior shell of the lens capsule is left in place.
    • Payment is per eye and is the number one procedure performed in ASC’s. For ultrasonic determination of intraocular lens power, use 92136 or 76519.

  • 66982: Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (i.e. irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (i.e. iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage.

    • Payment is per eye, secondary fixation of IOL is included. Complex cases are roughly 5% of cataract surgeries performed.

    • Indications for coding complex cataract surgery include:

      • A miotic pupil that will not dilate sufficiently to allow operative access to the lens and that requires the insertion of one of the following: four iris retractors through four additional incisions; Beehler expansion device; a sector iridectomy with subsequent suture repair of; iris sphincter; or sphincterotomies created with scissors.

      • The presence of a disease state that produces lens support structures that are abnormally weak or absent. This requires the need to support the lens implant with permanent intraocular sutures, or a capsular tension ring may be necessary to allow placement of an intraocular lens.

      • Pediatric cataract surgery.

Coding Tips for Common Ophthalmology Services: Part Two

This is the second blog in a two part series on common ophthalmology services and how to avoid billing errors. To reduce the risk of an audit and costly billing mistakes, here are some tips on common ophthalmology tests and procedures.

  • Fluorescein angiography. Use CPT code 92235, Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral. This test is used for evaluating retinal, choroidal, and iris blood vessels, as well as any eye problems affecting them. Fluorescein dye is injected into an arm vein, then rapid, sequential photographs are taken of the eye as the dye circulates. The cost of the dye is not separately payable and this code does not include fundus photos (CPT 92250). When medically necessary this test is payable during the global postoperative period whether related or unrelated to the surgery.
  • Fundus photography. Use CPT code 92250, Fundus photography with interpretation and report. Fundus photography is a process of using special optical imaging equipment to document the diagnosis and treatment of diseases of the eye. Fundus photography may be indicated to document abnormalities related to a disease process affecting the eye, or to follow the course of such disease. It also lends itself to the assessment of a wide variety of retinal disorders. Photography documenting external eye abnormalities may also be necessary. Payment for this test is bilateral. When medically necessary this test is payable during the global postoperative period whether related or unrelated to the surgery.
  • Excision of lesion. The CPT code to use depends on the size of the lesion: 68110 (excision of lesion, conjunctiva, up to 1cm), 68115 (excision of lesion, conjunctiva, over 1 cm), 68130 (excision of lesion, conjunctiva, with adjacent sclera). The criteria for modifier -25 must be met when billing an established patient office visit the same day that CPT code 68110 or 68115 is performed. Payment is per eye. A biopsy and excision of the same lesion are not payable on the same day. CPT codes 68110 or 68115 are appropriate for pinguecula excision based on size. For Medicare Part B patients, when surgery is performed bilaterally, submit one line item with the surgical code appended by modifier -50, with a 1 in the unit field and the charge doubled.
  • Trabeculoplasty. Use CPT code 65855, trabeculoplasty by laser surgery; also known as ALT or SLT. This laser surgery removes part of the trabecular meshwork to increase outflow of aqueous from the eye; a type of filtering surgery used in the treatment of glaucoma. Known as Argon laser trabeculoplasty (ALT), Micropulse laser trabeculoplasty (MLT), and Selective laser trabeculoplasty (SLT). Payment is per eye. The global period for Medicare patients is 10 days. The global period for non-Medicare patients is 90 days. Modifier -57 should be appended to the office visit when an ALT/SLT is performed the same day for a non-Medicare patient. Do not report 65855 with 65860, 65865, 65870, 65875, 65880.


Coding Tips for Common Ophthalmology Services: Part One

We’ve all heard the saying “it takes a village” - and this includes ophthalmology billing and coding. Exams, testing, and minor and major surgical procedures all take a team to coordinate and complete. The physician is ultimately responsible for selecting the proper code, however, it takes a team effort to properly document, code, and bill for these services. In this two-part series, we are giving you a review of frequent services and how to avoid billing mistakes.

  • Foreign body removal. Use CPT code 65222, Removal of foreign body, external eye; corneal, with slit lamp. This code has a zero day global period and is paid per eye. When the patient comes back a few days later for a follow up visit, it is a billable exam. If a rust ring develops, 65222 is the CPT code to use.
  • Benign skin lesions. The CPT code to use depends on the size of the lesion: 11440 (diameter of 0.5 cm or less), 11441 (0.6 to 1 cm), 11442 (1.1 to 2 cm), 11443 (2.1 to 3 cm), 11444 (3.1 to 4 cm), or 11445 (4 cm or greater). Medicare and non-Medicare payers cover benign skin lesion removal with proper documentation. A photograph is beneficial in the patient’s medical record. The chief complaint should include words like red, growing in size, oozing, and itching. Since this procedure may be considered cosmetic, it is helpful to obtain an ABN from the patient. Adding modifier –GA to the claim shows that an ABN is on file.
  • Punctum plugs. Use CPT code 68761, closure of the lacrimal punctum; by plug, each. This code has a ten day global period and is paid per eye. If both eyes were done, use 1 unit, modifier -50. This code has a Medically Unlikely Edit (MUE) of 4 per Medicare, meaning “ the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.” In most cases of dry eye syndrome requiring punctum plugs, placement of one plug in each lower punctum will alleviate the problem, in which Medicare will reimburse for two plugs per patient on a single date of service. Two additional plugs may be done (total of 4), and documentation must show the two additional plugs were medically necessary.
  • A-scan ultrasound and IOL Master for intraocular lens calculations. Use CPT code 76519 when billing for an A-scan, ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation. Use CPT code 92136 when using an IOL Master, ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation. Medicare and most commercial payers have a global technical component, modifier –TC, and each eye has a professional component, modifier -26. You may come across a few payers who do not recognize these modifiers, in which case use –RT and –LT.


More Money in the Bank: Best Practices for Improving Your Practice A/R

Well-run practices watch their collections like hawks. The financial health of your practice is directly correlated with your A/R numbers. How can you bring in the most cash? How can you collect the most amount of money with the least amount of time and effort? These are questions your practice needs to think about when addressing A/R numbers. Below are tips to help you improve your practice A/R.

  • Enforce practice financial policies.  Make sure your practice has a written financial policy in place that clearly defines a patient’s financial responsibility and delineates staff responsibility in collecting fees. Once you have established written policies for collections with your patients, make sure your staff is enforcing them. Do now allow exceptions.
  • Do not extend credit to patients.  Have patients pay their share in advance or as they go. It’s important to give them payment options. Accept cash and credit card payments. Give discounts to cash patients. If necessary make them charity cases or refer them out. Do not become a credit company.
  • Solve collection problems in advance with financial policy agreements.  Give each patient a financial policy to sign so they understand their payment obligations. By letting patients know up front what’s expected of them, and educating your staff on the policies and procedures to follow, you can plug the financial drain that nonpaying patient’s put on your practice.
  • Never avoid money discussions.  Talking to patients about money should be as easy as talking to them about their health or their families. Discussing and resolving money issues is important if you care about the patient’s well-being. Don’t allow a patient’s financial issue stop a needed procedure.
  • Manage collections by the numbers.  Monitor your billing staff productivity with reporting available through your practice management system. Set quota targets and reward improved performance. Your billing and collections staff should know the priorities of the practice to collect the most money possible.
  • Give insurance companies no slack.  The longer an insurance company can hold onto your reimbursements, they more money they make. Start with clean claims and make sure your patient data is accurate. Include medical records or other documentation that you know the insurance company will want. Fight every denial through phone calls and correspondence with the insurance company.



Boosting Patient Collections Up Front

With rising out of pocket costs in the healthcare system, the shift to patient financial responsibility is increasing. A Kaiser Family Foundation found the average deductible increased 32% from 2009 to 2014. Educating front desk staff, insurance verification, and a clear office financial policy are important components in collecting payments up front. Any of these small tweaks can make a positive impact to the overall financial health of your practice.  

  • Communicating with patients about their insurance coverage is an integral part of collecting fees up front. Staff should be checking insurance eligibility 24-48 hours prior to the patients visit. Train your staff to ask the patient if they have a new insurance policy. Don’t rely on the patient to let you know what their current coverage is. Be sure you are making a copy of all insurance cards to make the billing process efficient.

  • Have a financial policy. Make financial policies clear-cut and specific. Proper communication helps set the right expectations between the patient and staff. Collections, co-payments, and other payment policies must be in terms that are easily understood. To ensure effective financial policies, staff should be properly trained and understand what is expected of them. At the end of the day you are running a business and the financial health of your practice is crucial.

  • Provide price transparency and collect a pre-surgical deposit. Giving patients figures and data will help them determine how they can pay for their care. Offer payment options such as credit cards and Care Credit. Make sure you have verified with the insurance company whether pre-authorization is required for surgery.

  • All co-payments and fees for non-covered services should be collected up front at the time of service. Collecting prior to the visit reduces headache at the end of the visit. When calling patients for their appointment reminder, let them know they need to be prepared to pay their co-payments, deductibles, non-covered services such as refractions, and all past due balances. With rising out of pocket costs, the number of patients who have balances after their insurance processes the claim is increasing. If you do not have proper billing and collection processes in place, your accounts receivable will increase. As your accounts receivable ages, the possibility of collecting money decreases.