Ophthalmology and Optometry Coding Alert

Also: Watch for these new eyelid reconstruction Correct Coding Initiative edits.

If your ophthalmic surgeon performs eyelid repairs and reconstructions, heads up. The Correct Coding Initiative wants to make sure you're paying attention to CPT® definitions -- and if you're not, you could find yourself with claims denials on your hands.

CCI released version 18.0, effective Jan. 1, revealing 15,530 new active pairs and 6,197 code pair terminations, according to Frank D. Cohen, MPA, MBB, senior analyst with Frank Cohen Group, LLC.

Of special concern to ophthalmology coders are the bundles affecting eyelid excision and repair codes 67961 (Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin) and 67966 (... over one-fourth of lid margin). According to CCI, these codes are now bundled with 15004 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues], or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/ or multiple digits; first 100 sq cm or 1% of body area of infants and children).

Rationale: Medicare is clarifying CPT®'s definition of these eyelid repair and excision procedures. CCI has bundled code 15004 as a Column 2 code into the Column 1 codes 67961-67966, which means that Medicare considers 15004 to be an intrinsic part of the 6796x procedures. Note that the code definition for 67961- 67966 already includes the phrase may include preparation for skin graft ..., indicating that preparation for the graft is considered part of the surgeon's work represented by these codes.

It makes sense that the codes are bundled since the code descriptor specifically states inclusion for preparation of skin graft, observes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Hospital Ambulatory and Network Oversight at the Mount Sinai Medical Center Compliance Department in New York City. I wouldn't expect both codes to be billed under normal circumstances, and the bundling edits were just a formality by Medicare.

Include Pedicle Formation, Flap Delays in Lid Reconstructions

CCI 18.0 also bundles codes 15576 (Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral) and 15630 (Delay of flap or sectioning of flap [division and inset]; at eyelids, nose, ears, or lips) into 67971- 67975 (Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid ...).

Unbundling opportunity: These bundles are all marked with modifier indicator 1, which may allow you to break the bundle. In certain clinical circumstances you can override -- not ignore -- CCI edits and receive separate payment for bundled codes. To find out if you can separately bill services, first check the modifier indicator in column F of the CCI spreadsheet.

How it works: All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2),explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver. Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI.

A 0 indicator means that you cannot unbundle the two codes under any circumstances. An indicator of 1, however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment.

Tip: The most common modifiers that Part B practices use to override an edit pair are 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when used with an associated E/M code, or modifier 59 (Distinct procedural service) when two non-E/M services are performed and no other modifier is available to report the two separate and distinct services. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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.

Don't miss: Many coders are too quick to turn to modifier 59 to break CCI bundles. But when another already established modifier is appropriate, it should be used rather than modifier 59.

Get the facts: For more on CCI edits and to find which ones impact your practice, visit the CMS website at www.cms.gov/nationalcorrectcodinited/ncciep/list.asp.