Ophthalmology and Optometry Coding Alert

Can you accurately code retinal detachments? Read more to find out.

When you look through the retinal repair codes in your CPT^® manual, it can be hard to differentiate between the dozens of coding options—because you know if you code incorrectly, you’ll face denials and slow payments.

Ophthalmology coder and subscriber Bernadette Brandys posed the following questions on this topic to Ophthalmology Coding Alert, and we enlisted our coding pro Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla., to weigh in in the answers. Read on to get the scoop on these common questions.

Question 1: Nail Down 67108 Requirements

Does our physician have to perform everything in the description for 67108 (Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique) to report the code? It says “and/or removal of lens by same technique,” so do we have to perform the lens removal? It also says, “including, when performed, air or gas tamponade, focal endolaser photocoagulation...” Are those optional? Our doctor always circles 67108 for vitrectomies even when he doesn’t remove the lens or perform tamponade. So is this code still accurate?

Mac’s Response:

The CPT^® code 67108 requires repair of retinal detachment with vitrectomy. If any of the services listed in the description of the code are performed, they are included with the retinal repair and vitrectomy and should not be coded separately. If, however, they are not performed, it is still appropriate to bill the 67108. Removal of the lens is not required to report this code.

Question 2: Remember Membrane Peeling for 67113

What would be the difference between the codes 67113 (Repair of complex retinal detachment [eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees], with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens) versus 67108? 

Mac’s Response: 

The main difference between these codes is that 67113 includes epiretinal membrane peeling. It is also important to note the word “complex” in the description of the 67113 code.  This doesn’t mean that the procedure was met with complications during surgery.   It does, however. mean that it is anticipated that the procedures will be complex prior to the start of the surgery.

Question 3: Mind Your CCI Edits

Can we report 67040 (Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation) with a 66852 (Removal of lens material; pars plana approach, with or without vitrectomy)? 

Mac’s Response:

The two codes are bundled by Correct Coding Initiative (CCI) edits and may only be separated and reported together if meeting the requirements for unbundling (review modifier 59 definition: Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.)

If appropriate, append modifier 59 (Distinct procedural service) unless a more specific modifier can be used to explain the circumstance of why both services should be paid.

Question 4: Review Modifier 59 Definition

Our surgeon performed a procedure yesterday and we’re trying to report 67042 (Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina [eg, for repair of macular hole, diabetic macular edema], includes, if performed, intraocular tamponade [ie, air, gas or silicone oil]) and 67039 (Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation). Can we report both, and if so, is a modifier necessary?

Mac’s Response:

The two codes are bundled based on CCI edits, and may only be separated and reported together if you meet the requirements for unbundling (again, review the modifier 59 definition listed in the answer to Question 3 above). If a more specific modifier besides modifier 59 can better explain why you should collect for both services, you should report that instead of modifier 59.

Resource: Do you have a question to pose to our experts? Send it to editor Torrey Kim at torreyk@codinginstitute.com.