Coding Corner CODING AND COMPLIANCE By:Joy Newby, LPN, CPC | Newby Consulting,Inc.
Denials for Second Eye A-Scans and Ophthalmic Biometry
The Centers for Medicare & Medicaid Services (CMS) changed the bilateral indicators for the professional components of a-scans (76519-26) and ophthalmic biometry (92136-26) on the Medicare Physician Fee Schedule Data Base (MPFSDB) effective with dates of service on or after January 1, 2017. Historically, the bilateral indicators for bilateral services allowed for unilateral reporting of the professional component. The bilateral indicators assigned to the global service (76519/92136) and technical component (76519-TC and 92136-TC) were not changed. The relative value units (RVUs) for these codes represent bilateral services, which means the payment for these codes is for bilateral services. Physicians should note that when the global and technical component is performed unilaterally, a -52 modifier should be appended to the code to indicate the test was performed unilaterally. In the narrative section, indicate the test was performed unilaterally. Novitas Modifier 52 and 53 Fact Sheet - Not all inclusive Modifier 52 Under certain circumstances a service or procedure is partially reduced or eliminated at the provider’s discretion. Example: Unilateral mammogram on right breast due to left breast mastectomy. Supporting Documentation Additional information to support modifier can be written in narrative of claim The professional component (interpretation and report) has always been a unilateral service, meaning this component could be reported for each eye tested. Novitas Coding Article number A53131, Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation provides the following instructions for reporting 76519-26 and 9213626 (Not All Inclusive) Coding Guidelines CPT codes 76519 (A-scan with IOL power calculation) and 92136 (Biometry by Partial Coherence Interferometry with IOL power calculation) have a bilateral technical component and a unilateral professional component. The professional component is normally done only for the eye for which surgery is planned. Therefore, when either 76519 or 92136 is reported, the reimbursement includes payment for both eyes for the technical component and one eye for the professional component. In this scenario, report 76519 or 92136 and indicate for which eye the professional component was performed (e.g., 76519 RT). Commonly, when a patient is diagnosed with bilateral cataracts, the surgeries are performed weeks apart. In this instance, an IOL power calculation is necessary prior to the second surgery. However, the technical portion of the test is not warranted again. In this scenario, it is necessary to indicate that only the professional component is being reported by appending the professional component “modifier 26” and identifying for which eye the calculation is being made, (e.g., 76519 LT-26 or 92136 RT-26). It is not appropriate for one physician/provider (physician “A”) to bill for the global service, and then another physician/provider (physician “B”) to bill for a re-read (professional component) of the same study. Cataract surgery should usually not be performed on both eyes on the same day, unless special circumstances exist (e.g., high risk for anesthesia, etc.). In situations when these circumstances do exist, it would be necessary for the IOL power calculation to be performed bilaterally. In this scenario, it is necessary to indicate that the technical and professional components are being reported for both eyes (76519-26-50 and 76519-TC or 92136-26-50 and 92136-TC). Below are examples of appropriate coding for 76519 and 92136: • Test is performed on both eyes (TC) but calculation is performed on left eye only. Report: 76519-LT or 92136-LT • Test is performed on both eyes (TC) but calculation is performed on right eye only. Report: 76519-RT or 92136-RT