Coding & Reimbursement

By Suzanne L. Corcoran, COE

Laser Trabeculoplasty

Clearing up LT confusion.

Trabeculoplasty performed with an argon or YAG laser is covered by Medicare when medically necessary. Physicians often consider it when pharmaceutical therapy is unsuccessful or unsuitable. Questions about Medicare rules still persist, so this month’s Q&A will attempt to clear up the confusion.

Q. How is laser trabeculoplasty (LT) billed? CPT code 65855, trabeculoplasty by laser surgery, one or more sessions (defined treatment series) describes LT. Both argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT) are described by 65855.

Medicare assigns 10 postoperative days to 65855, making this code subject to Medicare’s "minor procedure" rules. This means that the office visit on the same day as LT is included in the allowance for the procedure in most cases. However, when there is a separate and identifiable reason for the visit, it may be billed with modifier 25. Modifier 25 indicates that the patient’s condition required an additional service beyond the usual preoperative care. CPT adds that, "This [25] modifier is not used to report an E/M service that resulted in a decision to perform surgery," so just documenting the decision to proceed with an LT is not sufficient.

Q. Will a repeat procedure be covered? It depends on the purpose and timing of the second treatment. Note that the description of 65855 includes the phrase, "…one or more sessions (defined treatment series)." If the initial surgical plan describes multiple treatments in stages, then the second laser procedure is an extension of the first. In such cases, there is a short time interval between treatments and the second laser treatment does not warrant a separate charge. However, if the decision for each surgery is made separately after the prior treatment is no longer efficacious, and there is a long time between the first and second treatments, then each laser session is independent of the other and warrants a discrete charge.

The medical record must explain why medical treatment was not attempted first. Usually, the medical necessity for surgery depends on the failure of pharmaceuticals.

Q. May we use LT as a primary or initial line of treatment? In some cases, yes. The medical record must explain why medical treatment was not attempted first. Usually, the medical necessity for surgery depends on the failure of pharmaceuticals. In some cases, anti-glaucoma medications are contraindicated due to serious side effects, sometimes life- threatening ones.

Q. What documentation is required in the medical record? After the decision for laser surgery is reached, the chart documentation should include the information listed below. A form suitable for this purpose is available on our Web site.

• Discussion of indications for surgery
• Determination that medical therapy failed or was contraindicated
• Patient’s informed consent
• Laser operative report
• Physician’s signature

Q. What is Medicare’s reimbursement for LT? When LT is performed in the surgeon’s office or an ambulatory surgery center (ASC), the 2007 Medicare Physician Fee Schedule national allowed amount is $297.12. This amount is adjusted by local wage indices. There is no ASC facility fee for 65855 at this time.

When LT is performed in a hospital outpatient department, the surgeon’s reimbursement changes. There is a 15% reduction in the Medicare allowable, to $254.29.

Q. What is the frequency of LT in the Medicare program? CMS utilization rates for claims paid in 2005 showed that 65,855 were performed in 1% of all office visits. That is, for every 100 exams and consultations performed on Medicare beneficiaries, Medicare paid for this service once. Note that this CPT code does not distinguish between ALT and SLT. However, it is our belief that the majority of these cases were SLT procedures. OM