Ophthalmology and Optometry Coding Alert

If your ophthalmologists perform exams under general anesthesia, you may need to break the habit of coding them separately. Version 15.2 of the Correct Coding Initiative (CCI), effective as of July 1, bundles those exam codes into hundreds of eye surgery procedures -- but it does leave the door open for unbundling, if necessary.

CCI 15.2 includes over 3,500 new edit pairs, according to Frank Cohen, senior analyst with MIT Solutions, Inc. These edits affect nearly all medical specialties, including ophthalmology.

Codes 92018 (Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete) and 92019 (... limited) are now bundled into nearly all of the surgery codes listed in CPT's "Eye and Ocular Adnexa" section (65091-68850). This means that CCI has decided that an exam under anesthesia is an inherent part of these eye surgery procedures, and the reimbursement for the exam is included in the reimbursement for the procedure.

All of the bundles are marked with modifier indicator "1," allowing you use an appropriate modifier, such as modifier 59 (Distinct procedural service), when clinical circumstances warrant reporting 92018 or 92019 as a separate procedure.

Example: "One circumstance where physicians may find a need to perform an examination under anesthesia is with pediatric patients prior to a surgical procedure," notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. An ophthalmologist may not be able to perform an adequate exam on the patient if the patient did not cooperate due to young age and/or exam discomfort, or if the patient has learning disabilities or dementia, she said.

If you do report 92018 or 92019 with an eye surgery code without an appropriate modifier, Medicare (and other payers who adhere to Medicare's CCI rules) will only pay for the eye surgery code, which is in Column 1 of the CCI edit table.

Exceptions: When you look at the new CCI edits, available at www.cms.hhs.gov/NationalCorrectCodInitEd, you'll notice that the only primary eye surgery codes to escape the 92018-92019 bundle are:

• 65760 -- Keratomileusis

• 65765 -- Keratophakia

• 65767 -- Epikeratoplasty

• 65771 -- Radial keratotomy.

But Medicare will not cover these procedures in the first place; per Medicare's Physician Fee Schedule, they are marked with status code "N" (Non-covered service).Also not bundled are unlisted-procedure codes and add-on codes. Keep in mind: You cannot report an add-on code without a primary procedure code, and most of the primary procedure codes now include 92018 and 92019. Therefore, you are effectively prevented from  reporting 92018 or 92019 with any payable eye surgery code, without an appropriate modifier.

Codes 92018 and 92019 have been in long-standing mutually exclusive bundles with regular eye exam codes 92002-92014 (Ophthalmological services: medical examination and evaluation ...) -- but CCI 15.2 turns the tables.

Old way: Before July 1, codes 92002 (... with initiation of diagnostic and treatment program; intermediate, new patient), 92012 (... with initiation or continuation of diagnostic and treatment program; intermediate, established patient), and 92014 (... with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) were in Column 1 of the mutually exclusive edit table. If you reported 92018 or 92019 (which were in Column 2) with one of those codes, Medicare would only pay for the Column 1 code. Code 92004 (... with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits), however, was in Column 2. All of those edits were marked with modifier indicator "1."

New way: As of July 1, all of the 92002-92014 codes are in Column 2, and 92018 and 92019 are in Column 1. CCI has also changed the modifier indicator to "0," which prevents you from ever reporting those codes together, even with a modifier.

CCI 15.2 continues CCI 15.1's focus on +96376 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of the same substance/drug provided in a facility [List separately in addition to code for primary procedure]). That code is now bundled into exam under anesthesia codes 92018 and 92019, as well as these codes for special testing services, all of which involve injections:

• 92230 -- Fluorescein angioscopy with interpretation and report

• 92235 -- Fluorescein angiography (includes multiframe imaging) with interpretation and report

• 92240 -- Indocyanine-green angiography (includes multiframe imaging) with interpretation and report

• 92287 -- Special anterior segment photography with interpretation and report; with fluoresceinangiography.

Code 65756 (Keratoplasty [corneal transplant]; endothelial), introduced in CPT 2009, also receives +96376 as a component.

Combined with the edits introduced in CCI 15.1, this means that +96376 is now bundled into nearly all of the "Eye and Ocular Adnexa" surgery codes from 65091- 68850, all with modifier indicator "1." Note that exceptions " as with 92018 and 92019 " are 65760, 65765, and 65767, along with the unlisted-procedure and add-on codes.

Resources: For more information on previous +96376 bundles, see "CCI 15.1 Update: Watch Out for New Vitrectomy, Blepharoplasty Bundles" in Ophthalmology Coding Alert, Vol. 12, No. 4.

You can download a complete list of current CCI edits from www.cms.hhs.gov/NationalCorrectCodInitEd.