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Ophthalmology Coding Alert

Billing for Postoperative YAG Capsulotomy

- Published on Tue, Jun 01, 1999
When billing for a YAG capsulotomy (66821) during the postoperative period of cataract surgery done on the same eye, would you use modifier -79 or -58?, asks Tracy Duffy, billing manager for the Eye Center at Memorial, a six-ophthalmologist practice in Albany, NY. And then, if a YAG capsulotomy had to be done twice on the same operative eye after cataract surgery during the postoperative period, would you use -79, then -78, or would you use -58 for both?

The answer to the modifier question depends partly on the circumstances. We talked to two practices: One would use -78 (return to OR for related procedure during postoperative period), and one would use -79 (unrelated procedure or service by same physician during the postoperative period). But each had reasons for making the choice of modifier. And both agree that getting paid for the second 66821 during the postoperative period is difficult.

The postoperative period for this procedure is 90 days, and the fee for the cataract surgery is supposed to cover all care related to the surgery provided by the operating physician during that time period. Of course, there are often situations which arise, such as the YAG capsulotomy, which need to be performed and which ophthalmologists believe they should be paid for. Thats what modifiers are for. The question is, which modifier should you use? And bear in mind that the medical record must reflect patient complaint and medical justification for the capsulotomy in order to get reimbursed, no matter. Some Medicare carriers are even requiring explanations of the medical necessity (including a patient complaint of difficulty seeing, which is not correctable by refraction) when the capsulotomy is performed within 90 days of cataract surgery on the same eye.

Modifier -58

Modifier -58 (staged or related procedure or service by same physician during postoperative period) should not be used in this case, says Lise Roberts, a billing and reimbursement consultant, who specializes in ophthalmology, and vice president of Health Care Compliance Strategies, Inc., based in Syosset, NY. The Health Care Financing Administration (HCFA) expressly prohibits using the -58 modifier with any of the laser codes for ophthalmology, Roberts explains. This is because all of the ophthalmology laser codes are described in CPT as being done in one or more sessions/stages. This supersedes the use of the -58 modifier, she states. HCFA has determined that one or more sessions/stages means that the original fee paid for the procedure includes any additional laser procedures of the same type on the same eye for a 90-day period after the first laser procedure. In general, modifier -58 should not be used in cases such as this, but there are rare circumstances that warrant its use (see [...]

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