Dispelling some common myths of ophthalmic surgery billing

McCune, vice president, Corcoran Consulting Group, San Bernardino, CA, reviewed seven common ophthalmic surgery billing myths that can lead to errors in filed claims. The meeting was sponsored by Johns Hopkins University School of Medicine, Baltimore, and Ophthalmology Times.

Myth 1

First, it is important to understand that the global surgery concept, established in 1992, refers to a single reimbursement amount for the preoperative, intraoperative, and postoperative care of a patient who has major or minor surgery, McCune said.

When more than one surgeon assists with the patient's postoperative care in a group practice, the global surgery concept still applies because the group bills the entire reimbursement amount.

"The physician who performs the surgery is shown as the performing surgeon," McCune noted. "Even though you may have not been the performing surgeon, the expectation is that you are going to take care of any of the patient's postoperative issues related to the surgery (being in a group practice)."

Myth 2

"If multiple procedures are performed at one session, the second through fifth are always reimbursed at 50% of the allowable."

This is not the case if the multiple procedures are bilateral procedures, McCune said. She gave an example of a surgeon who performed bilateral blepharoplasties and ptosis repair on both eyes during the same surgery. The first blepharoplasty is reimbursed at 100% and the second blepharoplasty is reimbursed at 50%, so there is one reimbursement amount for the bilateral blepharoplasty of 150%. The third and fourth procedures are paid at 37.5% each for the bilateral ptosis repair or 75%.

"We now see some reduction when previously surgeons would get 50% for all of the procedures subsequent to the first procedure submitted in this order," McCune explained. "If these procedures are not bilateral in multiples, then you don't have to worry."

Myth 3

"All laser surgeries are considered major procedures."

Laser surgeries should not be considered to all have the same postoperative period. When consulting the Medicare Physician Fee Schedule (MPFS), McCune noted that certain procedures, such as laser trabeculoplasty and closure of lacrimal puncta by laser, have a 10-day postoperative period, whereas others, like ocular photodynamic therapy, have no postoperative period.

In terms of laser surgery that requires multiple sessions, only one charge can be made for the total procedure, she noted. In the case of panretinal photocoagulation (PRP), repeated PRP within the 90-day postoperative period cannot be billed because it is part of the first payment.

"Some billing personnel will put the repeated PRP in the computer as a session with a zero, so that the laser treatments can be tracked and no claims are made," she said. "Otherwise those claims will not get paid and be returned as denied."

Chart documentation for laser procedures is also important. Make sure that the surgeon has carefully explained the indication for the procedure, any preoperative medications, the type of laser plus wavelength used, the power of the energy, size and number of treatment spots, the duration of the laser, and how the patient tolerated the procedure.