CODING Q & A

Doing Intravitreal Injections in an ASC Creates Issues

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. Could you please advise on how to bill for intravitreal injections in an ASC?

A. Intravitreal injection (CPT code 67028) is not on Medicare's list of approved ASC procedures; thus, Medicare will not pay for the service in this setting. However, because it is a covered procedure the facility cannot bill the patient. As strange as this may seem, the physician has to be billed for the procedure lest allowing the procedure to be performed in an ASC be considered an inducement for physicians and a violation of the anti-kickback regulations. This is a touchy issue and I recommend you seek legal advice and contact your carrier medical director for further clarifications.

Q. How can I bill the office visits by a general ophthalmologist and a retina specialist on the same day? Does it matter if it's the same practice?

A. Payment is made by Medicare for 2 office visits on the same day as long as 1 of them is a consultation and the other is an office visit (either E/M or Eye Codes). This is true if both providers are in the same practice or different practices — but in different practices it really is not an issue.

However, billing for 2 scheduled return office visits on the same day within the same practice is generally not allowed. Medicare regulations allow combining both services and billing at a higher level, if indicated; however, this usually presents financial allotment problems — so many practices elect not to pursue that route.

Q. I have heard conflicting information regarding modifier 52 and using it for diagnostic tests. What is it? When should we be using it? What happens if we don't use it?

A. First, the CPT definition: "52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician's election. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use)."

Next, you need to understand the concept of unilateral vs bilateral designation of diagnostic tests. Medicare annually prepares a Physician Fee Schedule Database that contains all the CPT codes and a wealth of other information for the specialist. Included are the RVUs, global fee information, PC/TC (Professional Component/Technical Component) indicators, multiple procedure indicators, bilateral surgery indicators, assistant surgery indicators, co-surgery indicators, team surgery indicators, and more.

For this discussion we look to the bilateral surgery indicators, though we are dealing with diagnostic tests. The indicators state whether a test is unilateral (paid for each side at 100% of the allowable, such as extended ophthalmoscopy, fluorescein angiography) or bilateral (the allowed fee includes performing the test on both sides, in our case, on both eyes.)

Each ophthalmic diagnostic test is thus classified for payment purposes. In retina, common unilateral tests include, in addition to those already mentioned, OCT, ICG, and B-scan. Bilateral tests include gonioscopy and fundus photography.

When a test designated as bilateral (ie, fundus photos) is only performed on 1 eye, modifier 52 is added to show that the service is reduced. Payment was originally calculated on the basis of the test being performed on both sides and when it isn't, you must indicate a reduced service. There is no associated payment reduction — that is done on the local Medicare carrier level, and thus will vary. Indeed, sometimes it isn't reduced at all.

However, under audit you must be able to prove that you indicated that you performed a reduced service when the claim was submitted.

CPT codes copyright 2006 American Medical Association. RP