Here’s how to find your way through the coding maze. Glaucoma is changing not only in diagnosis and management modalities, but in coding and reimbursement. Optimizing reimbursement involves careful coding and correct use of evaluation/management and ophthalmology codes, proper selection of surgical procedure codes, and proper billing of diagnostic tests.

Evaluation/management (E/M) codes are often employed in glaucoma coding. Glaucoma specialists are frequently called on for consultations, and all consultation codes are E/M codes. Remember, you must adhere to those guidelines and perfect your chart documentation, too.

• Bundling codes. As of January 1, 1998, gonioscopy was bundled with the ophthalmology codes (92004, 92014, 92002, 92012) but not the E/M codes.

Use caution when you’re billing an ophthalmology code — you may find it to be more advantageous to use the E/M code, plus gonioscopy, when doing so is appropriate. Also, remember that serial tonometry (92100) and tonography (92120) are bundled with the ophthalmology codes, so in order to be reimbursed for both the office visit and the test, you should use an E/M code.

• Coding for your time. In a glaucoma practice, you’ll often encounter acute problems requiring the patient to remain in the office for a prolonged period while he’s being treated and monitored. You can obtain payment for your extra effort by using the procedure codes for prolonged services (99354-99357).

Be especially careful to remember that this is for face-to-face time with the physician only. Technician’s time doesn’t count. It’s the amount of time spent over and above the face-to-face physician time as described for each E/M code (if they’re used).

Instructions aren’t specified for the ophthalmology codes but they might be specified (45 minutes for 92004, 25 minutes for 92014, 20 minutes for 92002, and 15 minutes for 92012), based on the relative value units (RVUs) of the E/M codes .

Coding for glaucoma surgery has become more complex. Learn when to use code 66170 vs. code 66172. Here are some other tips.

• Procedure code 66172. Use this code when billing a trabeculectomy if any ocular surgery was previously performed on that eye. Procedure code 66172 has a modestly higher payment rate than 66170.

Both codes include antifibrinolytic agent use, such as mitomycin. You can’t bill additionally for use of such a substance during surgery. However, 5-fluorouracil (FU) injections aren’t included in payment of these procedures and, if performed during the global period, are additionally payable by appending the -79 modifier. Some carriers require modifier -58 instead.

If 66172 is repeated in its global period, bill it with a -78 modifier.

• Needling the bleb. You may be reimbursed for needling the bleb in the global period of a trabeculectomy if you do it in an operating room. The code is 66250 (revision or repair of operative wound of anterior segment, major or minor procedure). Append a -78 modifier.

If you perform the needling at the slit lamp in a patient examination lane, it’s considered part of postoperative care not warranting additional payment. The rationale is that the -78 modifier mandates a return to the operating room for a problem encountered because of the original procedure. Medicare defines an operating room as an operating room in a hospital or ambulatory surgery center, an endoscopy suite, or a laser suite (devoted exclusively to laser surgery). A problem that’s manageable in the office doesn’t warrant extra payment.

• Scleral reinforcement. Scleral reinforcement with graft (67255) is bundled with the trabeculectomy codes but not with the aqueous shunt codes (66180, 66185) and may be used with these codes.

• Suture lysis. Don’t bill for laser suture lysis using code 66250. Several Medicare medical directors concur that this is an obligatory portion of postoperative management and shouldn’t be billed in addition to the surgery.

• Sessions vs. stages. Remember the difference between sessions and stages. Laser trabeculoplasty is performed in sessions, if not done all at once. The sessions should not be billed separately.

• Modifiers. Modifiers are important. Use modifier -79 not only for surgical treatment of an unrelated problem, but also for 5-FU injection after trabeculectomy. The supply is billed separately. It was used for engendering payment of a greater procedure (trabeculectomy) after a lesser one (laser trabeculoplasty), but that use has now been assigned to modifier -58.

Visual fields, fundus photography, serial tonometry, tonography, provocative tests for glaucoma, extended ophthalmoscopy and scanning computerized ophthalmic diagnostic imaging all require that an interpretation and report be provided in the patient record.

Interpret the test and provide a comparison with previous tests, if applicable. Place an order in the chart for each special test. Know which are unilateral, meaning you can bill for each side (92135, 92225, 92226) and which are unilateral/bilateral, meaning you receive the same payment for one or both eyes (92081, 92082, 92083, 92250). -- Riva Lee Asbell, Coding consultant (phone: 215-629-9221, fax: 215-629-9042.)