When should the charge for ultrasound biometry

When should the charge for ultrasound biometry with IOL calculations be submitted to insurance: on the day it is done and interpreted, or on the day the cataract surgery is performed?


Answer: In most Medicare carrier areas, the A-scan can be billed when it is performed; you do not have to wait until the cataract surgery. A few Medicare carriers still require that the date of surgery be entered on the claim in the note or comment field when billing for this procedure, but most do not. Check with your Medicare carrier for any unique claim filing requirements they may have.

HCFA policy even allows the A-scan to be billed for both eyes at the same time when both cataracts will be operated on within a short time frame. This is why most Medicare carriers no longer require the A-scan to be billed on the day of surgery.

Answers contributed by Lise Roberts, vice president, Health Care Compliance Strategies, Jericho, N.Y.; Raequell Duran, president, Practice Solutions, Santa Barbara, Calif.; and Michael X. Repka, MD, American Academy of Ophthalmology representative to the CPT Advisory Committee.

NCCI 11.3 Update: Include Duct Probe in Dacryocystorhinostomy

The latest bundles also clarify the rules for IOL exchanges
You probably won’t tear up when you see what NCCI is up to this quarter--unless your practice spends a fair share of its time performing nasolacrimal probes.

NCCI version 11.3, that took effect Oct. 1, specifies that CPT codes 68810 (Probing of nasolacrimal duct, with or without irrigation) and 68811 (… requiring general anesthesia) are included in:

• 31239--Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy

• 68530--Removal of foreign body or dacryolith, lacrimal passages

• 68720--Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity).


Translation: You can no longer report 68810 or 68811 along with those three codes unless it is a separate procedure, marked with modifier 59 (Distinct procedural service).

Additionally, NCCI has determined that 68840 (Probing of lacrimal canaliculi, with or without irrigation) is included in 68530 and 68700 (Plastic repair of canaliculi).

NCCI 11.3 also addresses IOL insertions and exchanges. IOL insertion procedure 66985 (Insertion of intraocular lens prosthesis [secondary implant], not associated with concurrent cataract removal) includes 65920 (Removal of implanted material, anterior segment of eye) as a component, so you should not report those two codes together unless you can justify appending modifier 59. Code 66986 (Exchange of intraocular lens) now also includes 66985, since NCCI identifies 66986 as a “more extensive” procedure.

Removal of implanted material (65920) is already bundled into IOL exchanges (66986), says Christina Hollis, OCS, coder and surgery scheduler at Pediatric Ophthalmology Associates in Columbus, Ohio.

Bottom line: Don’t attempt to report an IOL exchange by using both 66985 and 65920. The NCCI edits have assigned a bundling modifier “1” to these codes, so unless there is evidence of a separate anatomical site (separate eye), reporting these procedures together is prohibited. If the ophthalmologist both removes an old IOL and inserts a new IOL, report 66986, which specifically describes IOL exchanges.

Coding 65920 with 66986 is inappropriate “because the removal of the IOL is an integral part of an IOL exchange,” Hollis says. “You’d basically be paid twice for removing the IOL. The same reasoning applies to 66985 and 66986--you’d be paid twice for inserting the new lens.”

Note: NCCI 11.3 takes effect on Oct. 1. To download the complete set of NCCI 11.3 edits, visit the Web site www.cms.hhs.gov/physicians/cciedits.

No Need for Ob-Gyn's Presence on TC/26 Code

Question: We-re charging for a fetal non-stress test (NST). Is it OK if the ob-gyn was not present on the day the patient underwent the NST?

The code for the NST (59025, Fetal non-stress test) has both a technical (modifier TC, Technical component) and professional component (modifier 26, Professional component) and no requirement for direct physician supervision. 

Important: If your ob-gyn wasn't present for the NST performed at the hospital and documented the interpretation, you should report 59025-26. The hospital would then report 59025-TC. If the patient underwent the NST in the office, you should report 59025 alone.

61107 vs. 61210 Depends on Approach

Question: The physician determined that one of our patients had hydrocephalus and intraventricular hemorrhage. The patient underwent surgery in which the neurosurgeon made a small incision at the level of the coronal suture. The doctor removed a small portion of the right frontal bone, coagulated the dura and inserted a ventricular catheter for drainage. What code should I report?

Answer: If he used a twist drill to remove the frontal bone, you should report 61107 (Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording device). But if he made a burr hole, use code 61210 (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s] or pressure recording device [separate procedure]).

Typically, your physician will use the burr hole for more definitive procedures (such as ventriculoperitoneal shunts), and will use the (handheld) twist drill for quick catheterization of the ventricle, because it is packed with the catheter kit. Check the operative report (or consult with your doctor) to see which one applies in this case.

Find A-Fib Code at 427.xx

Which ICD-9 codes describe new onset atrial fibrillation and atrial fibrillation with rapid ventricular response?

Answer: The appropriate code for new onset atrial fibrillation is that same as for established atrial fibrillation: 427.31 (Atrial fibrillation).

This code is also appropriate for atrial fibrillation with rapid ventricular response.

Report 732.x Series for Juveniles

Question: Does the term "juvenile" in juvenile osteochondrosis (732.x) refer to the age of the patient or the stage of the disease? When the diagnosis is "osteochondral defect," which code should we report?

Delaware Subscriber


Answer: Because most osteochondroses are diseases affecting the growth centers in children, they are referred to as "juvenile." Therefore, the term refers to diseases affecting children, and the codes are not appropriate for adults. If you see a patient with the adult form of this disease, you should report 732.7 (Osteochondritis dissecans) or 732.8 (Other specified forms of osteochondropathy).

When your physician uses the term "osteochondral defect," he is referring to a defect in the articular cartilage - the tough, elastic tissue that covers the ends of bones in joints. Unfortunately, CPT does not include an ICD-9 code that specifically describes this condition, so you should report 717.9 (Unspecified internal derangement of knee) for it.


  - You Be the Coder and Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J.

You Shouldn't Code All ED-Related Care the Same Way

2 case studies show you when to bill a telephone call, consultation and admission


If you're providing emergency department (ED) services, such as phone care, in-person opinions, and hospital admissions, you should know that CPT applies different rules to each type of care.

Many pediatric offices no longer routinely admit patients to the hospital. So you may not be familiar with the codes you should use when a pediatrician provides occasional off-site or on-site ED care.

You can correctly code the pediatrician's services if you report the encounter based on the following expert-approved case studies:


Case Study 1: Pediatrician Provides Phone Advice


The scenario: An ED physician who is treating a suicide-attempt patient calls the teen-ager's pediatrician to ask about the patient's prior mental history.

What to report: You should submit a telephone call code (99371-99373, Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists] ...).

Common mistake: You shouldn't bill an E/M service code when a pediatrician doesn't see the patient in person.


Charge Indirect Care With Call Code


When a pediatrician only provides advice over the phone to an ED physician, you shouldn't code an ED service. "Codes 99241-99245 (Office or other outpatient consultations) require three of three key elements," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif. The pediatrician must perform a face-to-face history, examination and medical decision-making to report a consultation.

But no face-to-face contact exists when a pediatrician offers telephone care. So, the pediatrician cannot perform an exam, Jackson says. Therefore, you can't meet 99241-99245's examination requirement.

Solution: Select the appropriate-level telephone care code for the pediatrician's work. For the conversation between the pediatrician and the ED physician, you should assign 99372 (... intermediate [e.g., to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information and details, or to initiate new plan of care]). You would report 99372 because the pediatrician coordinated medical management of a new problem in an established patient.

Tip: If the insurer denies the telephone code, you may consider billing the patient. Before you do so, make sure the payer doesn't consider 99371-99373 a nonpaid covered service, says Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics national committee on coding and nomenclature.