Coding Q&A
"Interpretation and Report" for Diagnostic Tests
ANSWERS PROVIDED BY RIVA LEE ASBELL

Q: A friend was recently audited by Medicare and had to pay back the professional component for all his diagnostic tests, including fundus photos and fluorescein angiographies, for the past 5 years. Medicare said there was no interpretation and report. What do they want?

A: Medicare billing for diagnostic tests is often fraught with technicalities that must be mastered to optimize reimbursement while maintaining legitimacy. Extended ophthalmoscopy is one of the most heavily audited codes by Medicare in ophthalmology.

PROFESSIONAL/TECHNICAL COMPONENTS

A global fee exists for diagnostic tests; however there are two components: the professional portion and the technical portion. Certain tests that are solely physician services are not calculated this way, such as extended ophthalmoscopy and gonioscopy.

The technical component is often misunderstood. In practical terms, one may bill for the technical component if one owns the equipment and employs the technician, or performs the test personally. Technical component reflects reimbursement for the costs incurred by the physician.

Modifier -26 is used to indicate the professional component of a service, whereas modifier -TC is used to indicate the technical component. For any given service, the global fee is indicated by using only the procedure code. The professional component plus the technical component equals the global service or fee.

Some of the special ophthalmologic services pertinent to retina that have the requirement of interpretation and report in the CPT description include scanning computerized ophthalmic diagnostic imaging and optical coherence tomography (92135), extended ophthalmoscopies (92225, 92226), fluorescein and ICG (indocyanine green) angiographies (92230, 92235, 92240), and fundus photography (92250).

An interpretation and report should address the findings, relevant clinical issues, and comparative data (when available). A written report must be submitted that becomes part of the patient's medical record. This should be as complete as possible. This may result in duplicating information presented elsewhere in the medical record.

There should be an order in the patient record for the test, and medical necessity should be apparent. If not, then a written notation should be present explaining the rationale for ordering the test.

For example, the interpretation and report for extended ophthalmoscopy is not the drawing itself, but rather a succinct description of the findings and their pertinence for clinical management. The same applies to fluorescein angiography -- description of "early phase/late phase" does not fulfill this requirement. Rather, a statement of the diagnosis and the resultant clinical treatment is needed.

Q: Please explain why I should use CPT code 66850 rather than 66852 for lensectomy and vitrectomy?

A: CPT defines the 2 codes as follows:

► 66850: removal of lens material; phacofragmentation technique (mechanical or ultrasonic, e.g., phacoemulsification, with aspiration)

► 66852: pars plana approach, with or without vitrectomy.

Pars plana lensectomy goes back to a surgical technique wherein a primary cataract extraction was performed using a pars plana approach. Using this approach usually entailed incidental removal of some vitreous. The code is for primary cataract extraction and not for a pars plana vitrectomy with cataract extraction.

Confusion is abetted by the CPT instructions which state after the listing of pars plana vitrectomy codes (67036, 67038, 67039, and 67040): "For associated lensectomy, use 66850."

When vitreoretinal surgeons are performing a lensectomy and have used only a pars plana approach, it seems wrong to use a code that is specifically for an anterior segment approach. However, that is exactly what is supposed to be done.

Organized ophthalmology wanted to remove CPT code 66852 some years ago, however, the deletion was not approved by the CPT Editorial Panel, and now we do use it for some pediatric cataract extractions that are performed using this approach.

CPT codes copyright 2004 American Medical Association RP

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm in Philadelphia. You can contact her at (215) 629-9221 and via e-mail at rivalee@aol.com