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.