Reimbursement for Young Ophthalmologists: Top Rules With Case Examples—Part 2

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From residency to retirement, ophthalmologists can ensure appropriate reimbursement by understanding the fundamental rules of coding. Use the case studies in part two of this series to see how some of those rules are applied in practice.

Case #5: An Accidental Injury in Surgery’s Global Period

Scenario. You performed cataract sur­gery on the right eye of a 62-year-old woman. Two weeks later, she returns for an assessment of her left eye, which had sustained a blunt injury. You spot a small corneal abrasion of her left eye and apply some antibiotic drops. How do you properly code for an office visit that takes place during the cataract surgery’s global period?

Rule. Mastery of modifiers is essential for correct coding, and you should rec­ognize when to use the exam modifiers: –24, –25, and –57.

Applying the rule. The patient presented with a new diagnosis in the unoperated eye. Because the exam took place during the surgery’s global peri­od, you need to indicate to the payer that the exam was unrelated to that surgery. Do that by appending a modi­fier to the office visit code. In this case, you would use modifier –24 unrelated E/M [or Eye visit] service by the same physician during a post-op period.

Case #6: What, Me Worry? Audit Nonchalance

Scenario. The physician owners of a retina practice are hesitant to implement a comprehensive compliance plan. In the three years since it opened, the practice has never been audited and has received few claim denials. As a result, the owners assume that their current protocols must be, for the most part, accurate and they don’t see the need to “waste time” on internal chart audits. The claims have been paid, so they must be correct, right?

Rule. It is not a matter of if you get audited, but when you get audited. In­deed, the results of live polling during Codequest 2023 courses (aao.org/codequest) confirmed that the majority of ophthalmology practices have been audited within the last two years. Fur­thermore, the fact that you’ve been paid for a claim does not mean that you have done everything correctly. According to recent reports from the Supplemental Medical Review Contractor, audits of 2019 intravitreal injections found a 29% error rate. Even though practices have been paid for claims that failed the au­dit, those payments could be recouped. You should therefore take steps to make your coding and documentation audit-proof.

Applying the rule. Prepare for the inevitable audit by prioritizing internal chart audits. Use the Academy docu­mentation checklists (aao.org/coding) to identify any chart deficiencies and coding mistakes before the auditors can. For more on audits, visit aao.org/audits.

Case #7: Adding a Modifier, “Just in Case”

Scenario. An extended visual field exam (CPT code 92083) and an OCT of the optic nerve (92133) were performed during the same patient encounter. The biller was unsure whether 92083 and 92133 are bundled, and he appended modifier –59 to the OCT code “just in case” they were. Why was the claim denied?

Rule. Avoid guesswork in coding and billing and do not add modifiers “just in case”! Instead, confirm bundles prior to submitting your claims.

Applying the rule. CPT codes 92083 and 92133 are not bundled under the National Correct Coding Initiative; therefore no additional modifiers are necessary to unbundle them. Append­ing modifier –59 as a precaution may cause denials and increases scrutiny of utilization of the bypass modifier. Use internal quick reference guides to iden­tify any testing services bundles prior to claim submission.

Case #8: Surgical Complications, What’s Billable?

Scenario. A patient undergoes cataract surgery at a multispecialty practice. Afterward, he is referred to an internal retina specialist for complications from the cataract surgery. If the retina specialist examines the patient and determines that additional surgery is needed to resolve the complication, can the practice bill for the testing services and the appropriate level of E/M code?

Rule. Group practice physicians share the patient’s global period, and a new diagnosis doesn’t necessarily mean that the exam is unrelated to the surgery. You should consider whether the patient would have the problem if she had not had the initial surgery.

Applying the rule. When an examination is related to the initial surgery and performed during the global period by any physician within the same group practice, it is considered postoperative care and is not separately billable. Medically necessary testing services and surgeries are or surgery you must append the 58, –78, or –79) to the procedure code.

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Read Part 1 for Cases #1 (locum tenens), #2 (E/M versus Eye visit codes), #3 (new versus established patients) and #4 (bundling).