Talk to a billing specialist 
Medical Billing Blog

Tagged Under : , ,

2013 Medicare Physician Fee Schedule Final Rule Includes Additional 3 Percent Cut for Ophthalmology

James A. McNally, CPC, New Jersey Ophthalmology Assn.

The 2013 Final Rule on the Medicare Physician Fee Schedule was released with a number of significant changes. As a result, the American Academy of Ophthalmology (AAO) has provided a summary of key changes that will impact the practice of Ophthalmology:

  • 3 percent payment cut for Ophthalmology as a result of CMS’ implementation of cuts in reimbursement for eye codes when two or more diagnostic services are billed by the same physician on the same day for a patient.
  • Changes in work values for cataract and complex cataract surgery will also contribute to this 3% reduction.
  • Ophthalmologists face an additional 27 percent cut on January 1, 2013 unless Congress acts to derail the sustainable growth rate formula currently used to calculate Medicare physician pay. The final rule includes a conversion factor of $25.08, which reflects the SGR cut.

Read the entire article at


Avoid Coding Errors with Diabetic Retinopathy Coding

By The Coding Institute

Your practice could lose $1500 if you report 67210 or 67228 incorrectly. To navigate the DR maze, you first have to determine the kind of DR the patient has. Background–or nonproliferative–diabetic retinopathy (BDR or NPDR) is represented by ICD-9 code 362.01 (Background diabetic retinopathy).

Although BDR may never require treatment, in severe cases ophthalmologists use a focal laser (67210) to treat areas of edema resulting from leaking blood vessels. Using a grid pattern, the focal laser aims directly at the leaky sites to seal them off.

In most cases, the ophthalmologist is treating the edema, not the diabetes. Link 67210 to ICD-9 code 362.83 (Other retinal disorders; retinal edema) instead of 362.01.

Proliferative diabetic retinopathy (PDR) (362.02, Proliferative diabetic retinopathy) usually requires treatment. Instead of using the focal laser to seal off one site at a time, ophthalmologists use PRP (67228) to target the entire retinal area. Code 362.02 is the appropriate ICD-9 code for these cases.

Code Initial Treatment Bilaterally

Although BDR and PDR occur often in both eyes, the treatments for these conditions are inherently unilateral. If the ophthalmologist treats only one eye, report the laser code only once. But when the ophthalmologist treats both eyes during one session, report the laser code twice, either on one line (67210-50) or two lines (67210-RT, 67210-50-LT), for example, depending on the payer’s preference.

Medicare has assigned both 67210 and 67228 a bilateral status of “1” meaning that if you report them bilaterally, carriers will reimburse 150 percent of the fee schedule amount for a single code (or your total actual charge for both sides, if it’s lower).

For example, in 2012, payment for a bilateral PRP performed in an office setting would be 150 percent of Medicare’s fee schedule amount for a single 67228 ($1041.89), leading to approximately $1500 in reimbursement.

Avoid Reporting Repeat Sessions

Subsequent treatments of 67210 or 67228 on the same eye within the 90-day global surgical period are not separately billable, due to the “one or more sessions”?? verbiage in the code description.

Append Modifier 79 for Treatment in Different Eye

When a subsequent treatment within the postoperative period is in a different eye, you should code and bill this service with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

Important note: As is the case with modifier 79, the eye modifiers (LT and RT) are crucial. If modifier LT had not been used for the first procedure and modifiers 79 and RT used for the second procedure, the second procedure would look like an additional treatment on the same eye to Medicare and would be denied.

Billing Status:

Stop waiting for Your Money
Talk to a live specialist
or Call Us Today! @ 800-966-9270
Talk to a billing specialist 24/7