Can I Bill Fundus Photography and Retinal OCT on the Same Day?

Watch the video here.

I get asked this question often, I have also read many opinions about it and the answer is yes... kind of.

The more complete question looks like this:

"I have a patient who has moderate non-proliferative diabetic retinopathy and macular degeneration. I want to take a photograph to evaluate and monitor the retinopathy for changes and I also want to obtain a macular OCT to ensure there is no fluid from macular degeneration or diabetic macular edema. Can I just bill the fundus photograph with the ICD code for moderate diabetic retinopathy and the retinal OCT with the ICD code for macular degeneration?"

While I disagree with the following interpretation and use of the -59 modifier (I will explain more below), I have often heard this answered by saying "sure go ahead and use a -59 modifier for the OCT." If you were to do it this way the coding would look like this:

  1. 92250 E11.339 (Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema)

  2. 92134-59 H35.3132 (Nonexudative age-related macular degeneration, bilateral, intermediate dry stage)

The reason I disagree with this way of doing it is not that the provider will not get paid, occasionally they may. They will also be denied frequently, and if/when they do get paid, they will likely be required to pay back the money under an audit. Here is why, the CPT definition of the -59 modifier is:

"Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

Some clinicians will interpret the language "different procedure ..., different site or organ system" as being a circumstance where you are taking the photo of one "site" (retinal vessels) and the OCT of a different "site" (macula).

However, CMS is clear that these are not different sites: "The definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. … Treatment of posterior segment structures in the eye constitute a single anatomic site."

I will discuss when it would be appropriate to use a -59 modifier in a future post. For this situation there are two to be appropriately reimbursed for these 2 procedures.

  1. Use an Advance Beneficiary Notice (ABN). An ABN is used in when medicare (or other insurers) will cover a procedure in some circumstances but in this particular circumstance they will not. This describes the situation perfectly. Medicare will reimburse for the 92250 and the 92134, just not on the same day. In this case we would have the patient decide if they wanted to be responsible for the 92134 once it is denied or they can choose not to have the test at all.

  2. Do the tests on different days. Obtain the fundus photograph on the same day as the office visit while the patient is dilated. Then have the patient back the next day to obtain the macular OCT without an office visit. Be sure to complete an interpretation and report for each test once it is completed.

For a deeper understanding of when to use ABNs, or you want an in-depth look at when to (when-not-to) use modifiers, check out EyeCode: Billing and Coding.

Have a great week, talk to you soon! - Chris