Ophthalmology and Optometry Coding Alert

If your practice has been performing the cutting-edge endothelial keratoplasty (EK) procedure, take care. Medicare's Correct Coding Initiative (CCI) clarifies what you shouldn't report with 65756 (Keratoplasty [corneal implant]; endothelial) if you want to receive pay for this service.

CCI released version 16.1 in late March, revealing 2,054 new active pairs and 1,947 modifier changes, said Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions. CCI 16.1, which took effect for dates of service April 1, 2010, and beyond, specifies that 65756 is mutually exclusive with several other corneal transplant and reconstruction procedures:

• 65710 -- ... anterior lamellar
• 65730 -- ... penetrating (except in aphakia or pseudophakia)
• 65755 -- ... penetrating (in pseudophakia)
• 65780 -- Ocular surface reconstruction; amniotic membrane transplantation
• 65782 -- ... limbal conjunctival autograft (includes obtaining graft).

As a Column 2 code, 65756 is also mutually exclusive with 65750 (Keratoplasty [corneal implant]; penetrating [in aphakia]) and 65781 (Ocular surface reconstruction; limbal stem cell allograft [e.g., cadaveric or living donor]).

Know the rules: If you bill two mutually exclusive procedures together for the same patient on the same date of service, with no modifiers appended, Medicare and other payers following CCI rules will only reimburse you for the procedure in Column

1. So if you report 65756 and 65710 together, Medicare will reimburse your practice for 65756 (the Column 1 code in that bundle) -- but if you report 65756 and 65750, Medicare will only reimburse for 65750.

Good news: CCI marks these bundles with modifier indicator "1," which allows you to append an appropriate modifier to the Column 2 code and receive reimbursement for both, if the medical record documentation meets and substantiates the circumstances for unbundling the two services, explains Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, director of Best Practices-Network Operations at Mount Sinai Hospital in New York City..

CCI 16.1 also bundles 67250 (Scleral reinforcement [separate procedure]; without graft) into 65756 as a "Column 1/Column 2" edit. This edit indicates that Medicare considers the work involved in 67250 an intrinsic part of the EK procedure (65756).

If you report the two together, Medicare and other payers following CCI will only reimburse for the Column 1 procedure, 65756.

With 28.95 total relative value units (RVUs) assigned, multiplied by the $36.0846 conversion factor, reimbursement for 65756 can run as high as $1,044.65.

Code 76513 (Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion [water bath] Bscan or high resolution biomicroscopy) is now mutually exclusive with 0187T (Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral) and 92135 (Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser], with interpretation and report, unilateral).

CPT introduced temporary Category III code 0187T in 2009. Anterior segment optical coherence tomography (OCT) did not fit under the existing posterior segment scanning code, 92135. Anterior and posterior segment scans use different light wavelengths and require different machines.

Among the thousands of new code pairs announced in CCI 16.1, there are a few others that coders will want to keep their eyelids peeled for, experts say. CCI bundles the following wound repair codes:

• 12011-12018 -- Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucuous membranes ...
• 12051-12057 -- Repair, intermediate, wounds of face,ears, eyelids, nose, lips, and/or mucous membranes ...
• 13150-13152 -- Repair, complex, eyelids, nose, ears, and/or lip; 1.0 cm or less.