Billing and coding for cataract co-management can be tricky. It’s important that all parties involved should get accurately reimbursed for their time and expertise. To explain cataract co-management Billing, we discussed everything starting from defining co-management; the relationship between involved parties; required forms to be filled; CPT codes and modifiers; and key boxes in the CMS-1500 form. Let’s begin with an understanding of what is co-management in cataract surgeries.

Defining Co-Management

The American Academy of Ophthalmology defines the co-management as, a relationship between an operating ophthalmologist and a non-operating practitioner for shared responsibility in the post-operative care period when the patient consents in writing to multiple providers, the services being performed are within the providers’ respective scope of practice and there is written agreement between the providers to share patient care.’

As per cataract co-management billing guidelines, it’s important to define the relationship between an operating ophthalmologist and a non-operating practitioner for shared responsibilities in the post-operative care period. The first question that has to be answered is who is seeing the patient for what appointments. You, as the optometrist, are doing the initial consult, but after the surgery, where will the patient go for their postoperative care? This can vary based on your OMD group as well as your comfort level as a practitioner. When co-managing cataract surgery, do you want to see the cataract patient at their 1-day post-op visit? The 1 week? The 1 month? Some surgeons prefer to see their patients at the 1-day visit.

This co-management system should also include automated scheduling of all necessary post-op visits on the same day as the patient’s surgical consultation. The ophthalmology surgical coordinator should have direct contact with your office and call to schedule all appropriate follow-up visits when necessary. This takes away any responsibility from the patient and ensures the patient will be seen for their necessary post-operative care. In addition to this appointment schedule, there has to be a specific paper trail between you and the ophthalmologist. These forms include an initial referral form from OD to OMD; a patient election for co-management form; a transfer of care form; and a post-operative assessment sheet. Both the patient election for co-management and transfer of care form is required if you are going to be reimbursed for co-management services. These forms must be signed by the patient and kept within the patient’s medical records.

Cataract Co-Management Billing

How do optometrists get paid for their time and co-management? The essence of cataract co-management billing lies with the procedure (CPT) codes, applicable modifiers, and transfer of post-op care date. Most patients that undergo cataract surgery will be using Medicare, we will refer to procedure codes and modifiers which are applicable while billing Medicare. You can refer to payer-specific billing guidelines as modifiers and CPT codes might change. 

Billing scenario: On the day of the surgery, the surgeon will likely bill out CPT code 66984 with modifier 54. Modifier 54 indicates the surgical event is a co-managed case. The optometrist will then bill out CPT code 66984 with Modifier 55 on the date that they see the patient, which indicates post-op management only. You have to use the modifier RT/LT to indicate which eye was operated on. Additionally, most patients will undergo surgery for their second eye during this ‘global period.’ Modifier 79 is used to identify that the surgery is unrelated to the first eye. 

Medicare assigns 80 percent of the reimbursement to the intraoperative service, so 20 percent is left for our co-management. Within that 20 percent Medicare splits it between co-managing providers based on the number of days each provider is responsible for post-op care during the global period (90 days post-op). Currently, most insurance carriers cover only basic IOL implants. As the co-managing doctor, it is encouraged to discuss all the options with your patients, including premium IOLs (astigmatism correction, multifocal correction) and the addition of laser, which will have the best visual result. The patient is responsible for these costs and depending on the relationship with your co-management provider, you may be eligible for additional compensation for the increased level of care required with these options.

Crucial Boxes in CMS-1500

• Ensure your diagnosis matches the surgeon’s diagnosis.
• Ensure your CPT code matches the surgeon’s CPT code: 66984 for regular or 66982 for the complex.
• The date of service is the ‘actual date of the surgery.’
• Box 33: Must contain the optometrist’s practice, not the surgeon’s practice.
• Box 17: Insert the surgeon’s name.
• Box 17B: Insert the surgeon’s NPI#.
• Box 19: Type in the following words and actual dates; ASSUMED 00/00/0000; RELINQUISHED 00/00/0000 (This is the 90-day global period. Date Calculator.)
• Box 24G: (days or units) Medicare replacements and commercial insurances will only accept ‘1’ unit and you bill for the total dollar amount of the co-management period.
• Initial Treatment Date, the Additional Claim Info tab must contain the date of surgery if the claim will be submitted electronically.
• 1st eye CPT-66984 or 66982, then modifier LT or RT, then modifier 55 for co-management.
• 2nd eye CPT-66984 or 66982 if during the 90-day global of the 1st eye then add LT or RT and both of the following modifiers: 55 for co-management and 79 for an unrelated procedure or service by the same physician during post-op care.
• If the 90-day global period is over before billing the 2nd eye, or you are only billing for one eye, then it gets coded like the 1st eye example above.
• Note that traditional Medicare will only accept ‘90’ units (or the actual number of days you co-managed the patient). In this situation, you would divide the number of days you co-managed the patient by your total co-management fee and bill that dollar amount as a ‘Per-day’ amount. Your state’s Medicare carrier may vary. For example, you may bill one payer: Units = 1 & Fee = $300. And for Medicare you would bill: Units = 90 & Fee = $3.33

As mentioned earlier, billing and coding for cataract co-management can be tricky due to the involved parties. MedicalBillersandCoders (MBC) which is a leading medical billing company can assist you in accurately billing for cataract co-management. Our complete optometry billing and coding services can help you receive accurate reimbursement for delivered services. To know more about our optometry billing and coding services, contact us at 888-357-3226 / [email protected]

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