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Optometry Coding & Billing Alert

Reader Question:
Replace Modifier 50 With Modifier 26 in This Scenario

Question: Our optometrist calculated IOL power in both eyes, and we reported 76519-50 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation; Bilateral procedure) but only got paid part of the fee. The same thing has happened when we report 92250-50. Should we have used the LT (Left side) and RT (Right side) modifiers instead?

Supercoder.com subscriber

Answer: Unfortunately, most payers won’t reimburse you the bilateral fee despite your use of modifier 50, even if the optometrist calculated the IOL power of both eyes. Replacing modifier 50 with the LT and RT modifiers won’t improve your payment odds either. To understand why, it’s helpful to know how Medicare’s Physician Fee Schedule values the procedures.

As it does with many other diagnostic tests, CMS divides the A-scan (76519) and the IOL Master (92136) into two components. The technical component (the actual performing of the test) is denoted with modifier TC (Technical component), and the professional component (viewing and interpreting the results) is denoted with modifier 26 (Professional component).

For most procedures, the technical and professional components have the same bilateral status — for example, 92250-TC (Fundus photography with interpretation and report) and 92250-26 are both considered inherently bilateral, denoted with modifier indicator “2” on the fee schedule. The reimbursement for all components of 92250 is based on both eyes being tested.