Ophthalmology and Optometry Coding Alert

Use Modifier -51 for Multiple Procedures

If your surgeon performs a sclerectomy in addition to a shunt procedure (66160, Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy), don't bill these separately, says Paula Thomas, CPC, billing specialist for Southeastern Retina Associates in Tennessee. NCCI bundles 66160 and 66180.
 
The shunt procedure may also require that the ophthalmologist perform a scleral patch graft (67255, Scleral reinforcement [separate procedure]; with graft) during the same surgical session.
 
The reason for the reinforcement is usually a sclera that is thin or weakened, sometimes from a previous surgery. The ophthalmologist performs this when inserting the shunt. If the graft is done on the same day as the shunt, report 67255 and append modifier -51 (Multiple procedures).
 
These codes are not bundled in the National Correct Coding Initiative, so carriers should reimburse you separately for these services. Modifier -51 indicates that "multiple procedures, other than E/M services, are being performed at the same session by the same provider ... the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier -51 to the additional procedure or service code(s)."
 
For example, if the procedures were done on the left eye, the form would look like this: 66180-LT on the first line, and 67255-51-LT on the second line.
 
Performing 67255 isn't medically necessary on every patient who gets a shunt. Documentation should include information about the scleral thinning or another reason for the reinforcement procedure.
 
For example, use 379.19 (Other disorders of eye; other disorders of sclera; other), an open-ended code.

Change Manuals to Collect for Supplies

For the shunt itself, use HCPCS code L8612 (Aqueous shunt). One problem that comes up with this procedure is failure to bill for the shunt itself in addition to the procedure, McCune says.
 
Another problem for coders arises when physicians use the brand name of the shunt-such as "Baerveldt" - in their operative report instead of specifically using the term "aqueous shunt," says Lolita Jones, RHIA, CCS, a coding consultant in Fort Washington, Md.
 
"If a coder is inexperienced in coding that particular procedure, they don't necessarily know what a Baerveldt implant is, so a lot of times I see it miscoded altogether,"  Jones says.
 
Remember that the physician can bill for the shunt only if the physician provided it at his or her cost.
 
Always check your local carrier policies regarding the use of HCPCS codes.
 
If your physician performs an aqueous shunt procedure in an ambulatory surgical center (ASC) that is owned by the physician or physician group, the supply billing is part of the ASC's claim, not part of the physician's claim.