Ophthalmology and Optometry Coding Alert

Also: TrailBlazer clarifies the acceptable diagnosis code for IOL exchange due to complications

If your ophthalmologist is performing the new Descemet's Stripping Lamellar Endothelial Keratoplasty (DSLEK) or Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK), you'll have some new coding guidance to help you get paid for the procedures -- at least if you contract with TrailBlazer.

     
The carrier has clarified the code to use for DSLEK and DSAEK, as well as the appropriate diagnosis you need when you report 66986 (Exchange of intraocular lens). Here's what you need to know to report these services to TrailBlazer and other carriers that follow their lead.

Tackle DSLEK/DSAEK With Unlisted-Procedure Code

Ophthalmologists are turning to the new corneal transplantation DSLEK or DSAEK procedures as an option for patients. In this procedure, the surgeon only replaces the diseased endothelium, instead of replacing the entire endothelium as in a standard penetrating keratoplasty (PKP). Your challenge becomes choosing the proper code to report when your ophthalmologist opts to use these newer procedures.

     
TrailBlazer has clarified that its contracted providers should report DSLEK/DSAEK with 66999 (Unlisted procedure, anterior segment of eye).

     
"The information regarding DSLEK/DSAEK will change our current coding practice," says Diana Alvarado-Gil with Focal Point Vision in San Antonio.

     
Important: In its Contractor Update, TrailBlazer suggests that you submit the operative report along with your claim "to help expedite claim payment."

     
"As long as they submit 66999 with their operative report, they will be paid, although 'what' they will be paid doesn't seem to have been issued in this release," says Kim Buckley, independent coding consultant in North Texas.

     
Caution: The carrier specifically states that you should not use 65730 (Keratoplasty; penetrating [except in aphakia]) to report DSLEK/DSAEK.

     
Biggest problem: The greatest impact, according to Buckley, is going to be on ambulatory surgical centers (ASCs). Trailblazer does not reimburse ASCs for an unlisted-procedure CPT code, she says.

     
"The way it will affect the doctors is, since this procedure is generally done in an ASC, and the ASC won't be getting paid ... the ASC is going to tell the doctor's office they can't do the procedures," Buckley says.

Avoid 379.31 With IOL Complications

 You already know that you should use 66986 when an ophthalmologist is exchanging an existing intraocular lens (IOL). But when the exchange is due to complications, which ICD-9 code should you use?

     
"In a recent meeting with the TrailBlazer Ophthalmology CAC representatives, it was brought to TrailBlazer's attention that many ophthalmologists are reporting ICD-9-CM diagnosis code 379.31 (Aphakia) when billing CPT code 66986 ... due to complications," TrailBlazer stated in its April 23 Medicare Contractor Updates.

     
TrailBlazer states that 379.31 is not the correct diagnosis code to report with this procedure. Instead you should use 996.53 (Mechanical complications due to ocular lens prosthesis).

     
The carrier offers examples of a dislocated IOL and an IOL with incorrect power as covered complications.

     
Good news: This may already be what you're doing when you report IOL exchanges due to complications. "The information regarding CPT code 66986 with diagnosis 996.53 is how we bill IOL exchange," Alvarado-Gil says.

     
"If the lens is being replaced for a complication, then 379.31 is wrong, and it shouldn't have been used in the first place," Buckley says. "The primary diagnosis should be the reason for the procedure, and if an IOL is being replaced for a complication, then the complication should be the diagnosis used."

     
Pointer: Medicare does not provide coverage for refractive issues. Per the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 16, Section 90: "Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage."