Coding & Reimbursement

Coding for the LT option

When medications are either ineffective or not viable in treating open-angle glaucoma, one option for the ophthalmologist may be laser trabeculoplasty (LT). Here’s what you need to know for correct coding.

Q. Does Medicare cover laser trabeculoplasty?

A. Yes, trabeculoplasty performed with an argon or YAG laser is a covered procedure when medically necessary.

Many ophthalmologists believe that trabeculoplasty should be considered when medical therapy with pharmaceuticals is unsuccessful or unsuitable.

Examples of unsuccessful or unsuitable include when the patient cannot tolerate the medications, the medications are not effective or the patient is noncompliant.

Q. May I use LT as a primary or initial treatment for glaucoma?

A. Sometimes; the medical record must explain why pharmaceutical treatment was not attempted first. Usually, the medical necessity for surgery depends on the failure of pharmaceuticals.

In some cases, anti-glaucoma medications are contraindicated due to serious side effects, sometimes even life-threatening ones.

Q. How should LT be documented in the medical record?

A. After the decision for laser surgery has been made, the chart documentation should include the following:

  • Discussion of the indications for surgery
  • Determination that medical therapy failed or was contraindicated
  • Patient’s informed consent
  • Laser operative report
  • Physician’s signature

Q. What CPT code describes this procedure?

A. Use CPT code 65855, Trabeculoplasty by laser surgery. Note that CPT does not specify the type of laser, so the same code is used for argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT).

Q. What is the global surgery field for this code?

A. Medicare assigns a 10-day postoperative period to laser trabeculoplasty. This makes LT a minor procedure according to Medicare.

Q. What is the Medicare reimbursement for 65855?

A. The 2017 Medicare Physician Fee Schedule allowable for LT performed in the surgeon’s office is $248. If LT is performed in an ASC or HOPD, the surgeon’s reimbursement changes the Medicare allowable and is reduced to $212. These amounts are adjusted by local wage indices.

If the procedure is performed in an ASC, the 2017 facility fee is $133. Remember that all procedures performed in an ASC are subject to Medicare’s Conditions for Coverage rules, which include a comprehensive H&P prior to surgery.

Q. May I charge for an office visit on the same day as LT?

A. Sometimes. Minor surgical procedures include the visit on the day of surgery in the global surgery package, unless there is a separate and identifiable reason for the visit.

Q. Which modifier would I use in this situation?

A. When there is a separate and identifiable reason for the visit, modifier 25 should be appended to the visit code. Modifier 25 indicates that the patient’s condition has required an additional E/M service beyond the usual pre-operative care provided for the procedure or service.

CPT adds that “… this [25] modifier is not used to report an E/M service that resulted in a decision to perform surgery.”

Q. What if there is an immediate postoperative pressure spike? Is the postoperative visit billable?

A. No. An IOP spike is expected as a known complication in a small percentage of patients. Medicare global surgery rules state that medical management of complications during the postoperative period which do not require a return to the operating room are included in the global surgical fee.

Q. What is the frequency of LT in the Medicare program?

A. CMS data for claims paid in 2015 show that Medicare paid for this procedure a little more than 150,000 times. Put another way, for every 1,000 exams for Medicare beneficiaries, Medicare paid for this service seven times.

Q. May I be reimbursed for a repeat LT on the same eye after the 10-day global period?

A. It depends on the purpose and timing of the second treatment. When there is a short time interval between treatments, the second laser treatment may not warrant a separate charge.

Q. What if the decision to perform the surgery is made separately?

A. If the decision for each surgery is made separately; if the prior treatment is no longer efficacious; and if there is a long time between the first and second treatments, then each laser session warrants a discrete charge.

Q. May LT be done on both eyes on the same day, or within a few days of one another?

A. The physician determines if it is appropriate to perform LT bilaterally, although most ophthalmologists do not recommend it. Medicare’s Medically Unlikely Edits and multiple procedure rules apply; if LT is done on both eyes on the same day, the reimbursement for the second procedure will be reduced by 50%. Bill as 65855-50.

When treating the fellow eye during the global period of the first procedure, use modifier 79 with 65855 on your claim. The reimbursement rate is not reduced. OM