Coding and Billing

Cataract Co-Management: Do You Know How to Code for It?

By Eric Botts, OD

Co-managing cataract patients is a major practice-building opportunity. Two keys: Form a clear agreement with surgeons, and effectively code for your services.

Working cooperatively with surgeons to provide pre- and post-operative cataract surgery care is a valuable opportunity. It is a chance to oversee the care your patients receive before and after their procedure thereby increasing the chances of a good outcome. It also is a chance to expand the services you provide patients and build your practice. The first step to forging a profitable cataract co-management niche is to have a good relationship with a successful surgeon who consistently has a positive outcome after cataract surgery.

ROB Bottom Line:
Cataract Co-Management

Every cataract surgical patient in my office generates office visits, refractions and a global period fee per eye. A typical cataract patient presents with blurry vision and glare as a result of a mature cataract, therefore I perform an office visit (99203, 99204, 99214, 92004, 92014) and refraction. In addition to the global period fee I charge for refraction before prescribing post-cataract eyeglasses.
Initial Office Visit 99203/99214 $105
Initial Refraction 92015 $24
Global fee $119 per eye =$238
Post-op Refraction 92015 $24
Total $391
Typically I see two to three cataract surgical candidates per month. So yearly income is $391 X 30 = $11,730 with no investment in advanced instrumentation. Specular endothelial microscopy 92286 is a billable procedure with any cataract diagnosis so an additional $102 for an average of five cataract patients per week equals $26,520 in additional income.

Ensure You Have a Co-Management Agreement

A Confirmation of Post-operative Co-management Agreement is required by Medicare to be in place for every patient sent out for cataract surgery.

Click HERE to Download the post-operative co-management agreement form I use.

This form explains that you the optometrist will perform post-operative care and contact the surgeon if the patient experiences any complications related to the cataract surgery. The surgeon will let you know, on a case-by-case basis, when it is appropriate to send the patient back to you for post-operative care. This may be the day after surgery or any time after that depending on what your surgeon feels is best. More important than when the patient returns is that they always do return to you for post-op care and continued care for the lifetime of the patient. This is imperative for you to retain all of your patients because you are in the best position to continue providing both refractive and primary eyecare for this patient.
Billing for Cataract Co-Management: 90-Day Period

Cataract is considered major surgery with a 90-day post-op global period. The total global period is 92 days including the day before and day of surgery, however, for our global period calculations we are only concerned about the 90 days following the day of surgery. The 90-day global period is 20 percent of the allowable Medicare fee, so, if for example, the allowed amount is $650 then 20 percent is $130.

$130/90 days equals $1.44 per day, therefore, you only need to know how many days you will provide care during the 90-day post-op global period to figure out what your fee will be. If you see the patient after the 22nd day of post-op care then you will bill 68 days at $1.44 per day or $98. If the second eye has surgery following the first eye, the global period fee is calculated the same way.

Ensure Patients Return to You After
Cataract Care by Surgeon

Co-managing cataract patients is necessary to keep your patients coming back after surgery. Several years ago, as the Medicare allowable for cataract surgery decreased significantly year after year, surgeons realized that one way to make it up is to add an optical dispensary to increase income for their practices.

The only way to guarantee your patients will return to you for continued care after surgery is to co-manage the post-op care with the cataract surgeon.

Once the patient returns to you it is imperative that you call the surgeon’s office and obtain the following information:
Date of Surgery
Surgeon’s End Date (your begin date is the next day)
Surgical procedure and diagnosis code (your insurance claim should match codes submitted by the surgeon)

In addition, when submitting your claim you must use -55 modifier to indicate you are providing post-op care only and the appropriate RT/LT modifier to indicate which eye surgery was performed on. Remember that your begin date is the day following the surgeon’s end date regardless of when you first see the patient during the global period. For example, even if you did not see the patient until the 89th day after surgery but the surgeon reports an end date 22 days after surgery then you may still submit for 68 days. Regardless of how many times you see the patient during the global period for complaints or issues associated with the surgery, your reimbursement is the same as determined above according to total days multiplied by fee per day.
So what happens if the patient comes in during the global period for a reason not pertaining to the surgery?
Answer: If you perform an office visit not related to the original surgery you must use a -24 modifier with the office visit (99201-99215) to receive reimbursement for it.
Do I charge the patient for refraction during the post-op global period?  
Answer: You should always charge and collect for refraction during the global period if you perform one since refraction is typically not covered by Medicare or most other medical insurance plans and must be unbundled from office visit or post-op global period.
When submitting your claim to Medicare you must understand how your carrier requires the information be submitted. Unfortunately, not all carriers require the same claim information. Most Medicare plans require date of surgery in box 24 and the number of days of post-op care provided in box G for days or units.

TrailBlazer is one Medicare carrier that requires the begin date in box 24 and the number of days of post-op care provided in box G for days or units.

If performing surgery on the second eye during the 90-day post-op global period of the first eye then you must use the -55, RT/LT and -79 modifiers to indicate over-lapping the initial global period.

The following are ICD-9 diagnosis codes for cataract:
366.01  . . . . . . . .Anterior subcapsular polar cataract, nonsenile
366.02  . . . . . . . .Infantile, juvenile, presenile cataract, posterior
. . . . . . . . . .subcapsular polar
366.03  . . . . . . . .Cortical, lamellar, or zonular cataract, nonsenile
366.04  . . . . . . . .Infantile, juvenile, presenile cataract, Nuclear
366.09  . . . . . . .Other & combined forms, non-senile cataract
366.10 . . . . . . . . . .Senile cataract, unspecified
366.11  . . . . . . .Pseudoexfoliation of lens capsule
366.12 . . . . . . . .Incipient cataract
366.13  . . . . . . . .Anterior subcapsular polar senile cataract
366.14 . . . . . . . .Posterior subcapsular, polar, senile
366.15  . . . . . . . .Cortical, senile
366.16  . . . . . . . .Nuclear sclerosis
366.17  . . . . . . . .Total or mature senile cataract
366.18  . . . . . . . .Senile cataract, hypermature
366.19 . . . . . . . .Senile cataract, other/combined forms
366.20 . . . . . . . .Traumatic cataract, unspecified
366.21 . . . . . . . .Traumatic cataract, localized opacities
366.22 . . . . . . . .Traumatic cataract, total
366.23 . . . . . . . .Traumatic cataract, partially resolved
366.31 . . . . . . . .Glaucomatous flecks (subcapsular)
366.32 . . . . . . . .Cataract in inflammatory ocular disorders
366.33 . . . . . . . .Cataract with neovascularization
366.34 . . . . . . . .Cataract in degenerative ocular disorders
366.41 . . . . . . . .Diabetic cataract
366.42 . . . . . . . .Tetanic cataract
366.43 . . . . . . . .Myotonic
366.44 . . . . . . . .Cataract associated with other syndromes
366.45 . . . . . . . .Toxic cataract
366.46 . . . . . . . .Cataract associated with radiation
366.50 . . . . . . . .After-cataract, unspecified
366.51 . . . . . . . .Essential or progressive iris atrophy
366.52 . . . . . . . .After-cataract, not obscuring vision
366.53 . . . . . . . .After-cataract, obscuring vision
379.31 . . . . . . . .Aphakia
379.32 . . . . . . . . .Lens, Subluxation
379.33 . . . . . . . . .Lens, Anterior Dislocation
379.34 . . . . . . . .Posterior dislocation of lens
379.39 . . . . . . . . .Lens, Other Disorder
743.30 . . . . . . . .Congenital cataract, unspecified
743.31 . . . . . . . .Congenital cataract, capsular/subcapsular
743.32 . . . . . . . .Congenital cortical and zonular cataract

743.33 . . . . . . . .Congenital nuclear cataract
743.34 . . . . . . . .Congenital total and subtotal cataract
743.35 . . . . . . . .Congenital aphakia
743.36  . . . . . . .Congenital anomalies of lens shape
743.37 . . . . . . . .Congenital ectopic lens
743.39 . . . . . . . .Congenital cataract and lens anomalies, other
996.53 . . . . . . .Mechanical complication due to ocular lens
. . . . . . . . . .prosthesis
998.82 . . . . . . . .Complication caused by fragments of lens in eye
V43.1 . . . . . . . .Pseudophakia – Lens replaced by other means
V45.61 .  .  . . . . . .Cataract extraction status
The CPT codes for cataract are the following:
66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis
66982 Complex procedure requiring devices or techniques not generally used in routine cataract surgery
Cataract co-management is an integral part of primary eyecare and is not complicated in most cases. If you work with a well-trained surgeon then negative outcomes are very infrequent.  Maintaining your patient base is critical in building a successful practice and keeping all of your patients is crucial to obtain maximum patient examination revenue.

Related ROB Articles

Treating Ocular Trauma: Do You Know How to Code for It?

Code Correctly for External Ocular Infections

Make the Treatment of Ocular Allergies a Practice Profit Center

Eric Botts, OD, is founder and president of OBC Billing Specialists, and president of InnovativeEyes, in Macomb, IL. To contact him: drvision@claimdoctor.net.

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