Got Ophthalmology & Optometry Coding Questions?

Posted on 10 May, 2019 |comments_icon 0|By Elizabeth Debeasi

Get money-in-the-bank answers to solve your ophthalmology and optometry claim challenges.

Can you afford to guess when the right code could mean a substantial difference in reimbursement? Uncertain reporting is a costly gamble. Still, it happens every so often. A chart leaves you guessing. What eye care coder isn’t occasionally puzzled?

If ophthalmology and optometry coding questions have you concerned about your bottom line, today’s post is for you. Prevent reporting errors from siphoning off your hard-earned pay with guidance to navigate a few common-but-costly coding scenarios.

Scenario 1: Pinpoint SLT, ALT Codes

If the physician performed SLT for glaucoma, which code should we report? What if he performs ALT?

Answer: Report any laser trabeculoplasty procedure — whether it’s argon laser trabeculoplasty (ALT), diode laser trabeculoplasty (DLT), or selective laser trabeculoplasty (SLT) — with 65855 (Trabeculoplasty by laser surgery).

Note: The postoperative period for 65855 is 10 days. The short time period makes sense because ophthalmic surgeons often perform trabeculoplasties in two parts. Frequently, the entire 360 degrees is not performed at one time because this could raise ocular pressure. The standard protocol is to do 180 degrees first and the remaining 180 degrees in a later session. This reduces the amount of laser energy entering the eye.

The 10-day global period means that the ophthalmologist can complete the procedure as soon as 11 days after the original session. There is no need to append a modifier to the CPT® code for the second trabeculoplasty surgery if it’s performed after the 10-day global period of the first surgery.

Scenario 2: Look to ‘G’ Code for Glaucoma Screening

We can’t find a code in CPT® for glaucoma screenings for Medicare patients. How do we report this?

Answer: Codes do exist for these services, but you will find them in the HCPCS manual rather than in CPT®. When you perform a glaucoma screening on a high-risk Medicare patient, you’ll report either of the following two codes:

  • G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist)
  • G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist).

The difference between G0117 and G0118 is that the physician performs the service described by G0117, while the physician supervises another clinical staff member in the code described by G0118. To qualify for G0118, the services must be furnished under the direct supervision of an ophthalmologist or optometrist. Direct supervision means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Often this is performed by a tech, but keep in mind that state laws dictate who can legally perform glaucoma screenings.

Bottom line: If the doctor is out to lunch, on vacation, out sick, or otherwise not available in the office, you cannot report a service as if it was furnished under the doctor’s direct supervision.

Keep in mind that these codes can only be billed once per year, and only for patients who do not currently have a glaucoma diagnosis. These are used for screening patients at high risk for the disease, but who don’t have it yet.

Scenario 3: Go Beyond Diagnoses for YAG Laser Denial

Our ophthalmologist used a YAG laser (66821) for a diagnosis of “vitreous strands” and billed H43.311, but I don’t see that listed as an acceptable diagnosis for 66821. Is there an appropriate ICD-10 code?

Answer: The ICD-10 code (H43.311, Vitreous membranes and strands, right eye) is not the problem here — it’s the CPT® code. In this case, you should report 67031 (Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery [1 or more stages]), even though it doesn’t specifically mention the YAG (yttrium aluminum garnet) laser.

Code 66821 (Discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [e.g., YAG laser] [one or more stages]) does specify the tool your ophthalmologist used, but not the work he did. Report 66821 only for after-cataract treatments with the YAG laser.

Contributing Editor: Torrey Kim
Learn More

Put an end to avoidable denials, needless audit risks, and debilitating payback demands with your monthly subscription to Ophthalmology & Optometry Coding Alert. Every issue of this indispensable resource delivers high-impact tips and advice as our experts tackle the revenue-risking challenges that threaten your claims and compliance success.

The Coders’ Specialty Guide 2019: Ophthalmology/Optometry includes all CPT® and HCPCS codes relevant to ophthalmology and optometry, simple descriptions that explain each code, expert advice for assigning codes, Medicare reimbursement details, diagnosis codes crosswalk, applicable modifiers, CCI edits, global days, code index, hundreds of anatomical illustrations, and more.


Elizabeth Debeasi
Marketing Writer/ Editor

Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of Telehealth services.

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