Tips for ensuring payment for in-office procedures and diagnostic testing
Diagnostic and treatment technology has expanded significantly in the realm of dry eye disease (DED). Here, I discuss the common in-office procedures and diagnostic devices considered reimbursable. A reminder: Medical necessity drives coding.
AMNIOTIC MEMBRANES
Code. CPT Code 65778 for both dry and cryopreserved amniotic membranes.
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Tips. The coverage policy should be checked and, if required, prior authorization obtained. Additionally, remember that other payers set their own fee schedule. The amniotic membrane is not paid for separately, and you cannot bill CPT code 92071 along with this code. Also, you cannot bill for an office visit on the same day. There is a zero day global period for this procedure. (See the table, below for the most common ICD-10 codes for amniotic membrane use for DED.)
PUNCTAL PLUGS
Code. CPT Code 68761, Code 88761-50 for bilateral, these codes do not make a distinction between the different types or brands of punctual plugs.
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Tips. Depending on the insurance, “E” modifiers may be used to identify which puncta were occluded; others will accept RT (right eye) and LT (left eye). Your ICD-10 diagnosis codes should indicate which eye is treated. If appropriate, an office visit on the day of punctal plug insertion can be billed using modifier 25, appending the office visit code. Two puncta occluded at the same appointment is considered multiple surgeries, meaning the first procedure (puncta) is reimbursed at 100%, the second at 50%, third and fourth at 37.5% each.
DIAGNOSTIC TESTING
• Tear Osmolarity Testing
Code. CPT Code 83861
Tips. This testing is billed for each eye using the CPT code twice on two lines, with the modifier LT or RT. Some carriers may deny the second tested eye, and it may need to be submitted as 83861 once on one line with no modifiers, but with two units of service. This testing is reimbursed to those who maintain a CLIA certificate or a CLIA waiver certificate. If you have a CLIA waiver certificate, you will also need to use a QW modifier, along with the laterality modifier; 83861-QW-RT.
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• MMP-9 test.
Code. CPT Code 83516
Tips. This too requires a CLIA certificate or waiver certificate for Medicare or Medicaid. The modifier of QW is used in those offices that have a CLIA waiver. When performing this test bilaterally, most payers prefer a 59 modifier for the second eye as well as the laterality modifiers RT and LT. This test should be billed with the CPT code twice on two lines with needed modifiers for each tested eye. As there are more modifiers with this test, it may be worth checking with your payers and keeping track of who requires what modifiers.
Side note: Ocular surface interferometry and meibography technically have the code 0330T for tear film imaging unilateral or bilateral with interpretation and report. However, at this time there is no reimbursement associated with this code, so it is not reimbursable and is usually an out-of-pocket cost for the patient.
FINAL WORD
It is helpful to have a medical consulting specialty group, but is not a necessity. Also having a dedicated coding and billing specialist in your office is well worth the investment when it comes to correct coding. OM
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