Ophthalmology and Optometry Coding Alert

Avoid Recurring Denials When Coding Recurrent Retinal Repairs

Published on Sat Mar 01, 2003

Don't split at the seams standing behind your coding method for recurrent retinal detachment repairs there's more than one way that you can code this procedure and get paid.

Two retinal repair codes top coders'charts as the most difficult to use: 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique) and 67112 ( by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair[s] using scleral buckling or vitrectomy techniques).

The confusion surrounding CPT codes 67108 and 67112 is attributable to the similarity in the language used in their descriptors and the failure of CPT to instruct coders on which code should be used for recurrent repairs. As a general rule, coders think of CPT code 67108 as representing an initial retinal detachment repair procedure and 67112 as representing subsequent retinal detachment repairs. But this rule of thumb does not always apply, and that's a good thing here's why.

CPT codes 67108 and 67112 just don't measure up when it comes to reimbursement. The RVUs for initial retinal detachment repair (67108) are significantly higher than the RVUs allotted to 67112, 39.33 and 33.21 respectively. In average dollar amounts, this translates into a payment of $1,360.50 for 67108 and just $1,148.80 for 67112 a difference of $211.70.

Take Our Advice for 67108

Lori H. Winnie, CPC, coding specialist with Southeastern Retina Associates in Chattanooga, Tenn., gives coders the following scenarios to illustrate how to use codes 67108 and 67112.

Do use code 67108 with a modifier to code a repair of a recurrent retinal detachment when the definition of the code is met. If the surgeon performs the elements that are described in 67108, he or she should use that code to bill the service regardless of whether the surgery is subsequent to an initial 67108.

For example, if a patient undergoes procedure 67108 in his right eye and three weeks later he returns with retinal detachment in his left eye, both procedures can hypothetically be coded with 67108 (for the first procedure) and 67108-79 (for the second procedure), if the documentation indicates that both retinal detachments used the treatment method outlined by the descriptor for 67108.

Remember that if you use modifier -79 (Unrelated procedure or service by the same physician during the postoperative period), either the second procedure must be linked to a diagnosis code different from the ICD-9 code linked to the initial procedure, or the second procedure must be performed on a different eye. Also, you should use eye modifiers (-LT and -RT) for services that are billed in the postoperative period and have global periods of their own.

Do assign code 67108, with only the -LT or -RT modifier, a second time to the repair of a retinal detachment:

If the second 67108 procedure is performed outside the 90-day global period of the initial 67108 procedure

If the second 67108 procedure is performed by a different physician who is not a member of your practice.

For a more complicated scenario, let's suppose a patient undergoes a retinal detachment repair, and just two weeks later that same patient returns because the retina re-detaches in the same location as the first. Under these circumstances, your instinct might tell you that you can append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the retinal detachment repair code. However, modifier -58 can't be used simply because another procedure is being performed to fix the initial problem, warns Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

Modifier -58 requires that you meet one of three criteria:
1. The subsequent surgery is planned prospectively at the time of the original procedure (staged)
2. The subsequent surgery is more extensive than the original procedure
3. The subsequent surgery is for therapy following a diagnostic surgical procedure.

The example above does not meet the first criterion because the physician did not plan for the retina to detach again, it does not meet the second criterion because the first and second procedures would be valued the same, and the third criterion also does not apply to the example. Therefore, you cannot append modifier -58 to code 67108 a second time under these circumstances.

Also, according to CMS, the -58 modifier cannot be used with any procedures whose descriptors indicate "one or more sessions." This caveat means -58 should never be used with any of the following codes:

65855 Trabeculoplasty by laser surgery, one or more sessions (defined treatment series)

66761 Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) (one or more sessions)

66762 Iridoplasty by photocoagulation (one or more sessions) (e.g., for improvement of vision, for widening of anterior chamber angle)

67141 Prophylaxis of retinal detachment (e.g., retinal break, lattice degeneration) without drainage, one or more sessions; cryotherapy, diathermy

67145 photocoagulation (laser or xenon arc)

67208 Destruction of localized lesion of retina (e.g., macular edema, tumors), one or more sessions; cryotherapy, diathermy

67210 photocoagulation

67218 radiation by implantation of source (includes removal of source)

67220 Destruction of localized lesion of choroids (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions

67227 Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; cryotherapy, diathermy

67228 photocoagulation (laser or xenon arc).

Use 67112 When Instructed by Your Carrier

You can't avoid using 67112 for the repair of a recurrent detached retina when your carrier has a specific policy that addresses this coding scenario, which is why you should always check your carrier's billing policy before choosing a method of coding.