Ophthalmology and Optometry Coding Alert

Also: Take note of these changes to your transluminal dilation coding.

If your cornea specialist has been performing amniotic membrane transplants for wound healing, watch out. The Correct Coding Initiative has just released Version 18.2 of its quarterly batch of coding edits, and you have a number of changes to take note of.

CPT® code 65778 (Placement of amniotic membrane on the ocular surface for wound healing; self-retaining) describes a procedure in which amniotic membrane is placed on the ocular surface similar to what you do with a contact lens. The membrane can sit on the eye for several days while the eye is healing. Code 65779 (...single layer, sutured )describes a similar process, with suturing the membrane into place. Both codes debuted in CPT® 2011.

As of July 1, CCI considers 65778 and 65779 to include these procedures::

• 65280 -- Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue
• 65286 -- ... application of tissue glue, wounds of cornea and/or sclera
• 65400 -- Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium
• 65410 -- Biopsy of cornea
• 66020 -- Injection, anterior chamber of eye (separate procedure); air or liquid
• 67250 -- Scleral reinforcement (separate procedure); without graft
• 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
• 92019 -- ... limited.

CCI has also bundled codes 65778 and 65779 into 65420 (Excision or transposition of pterygium; without graft) and 65426 (... with graft).

What this means: In this type of bundle, known as "Column 1/Column 2," "non-mutually exclusive," or "comprehensive/component," CCI has decided that one procedure is a necessary component of another, more complex procedure. If you bill the comprehensive (column 1) procedure along with the component (column 2) procedure, Medicare -- and payers who follow Medicare rules -- will only reimburse you for the comprehensive procedure, which usually has a higher reimbursement value.

Exception: These edits are all marked with modifier indicator "1," which means that you can report the two codes separately under certain circumstances -- for example, if the ophthalmologist performs the procedures on different eyes. You must append a modifier, such as modifier RT or LT to show that the procedure was performed on a different eye, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla., and Brooklyn, N.Y. Additionally, most payers expect to see modifier 59 (Distinct procedural service) appended to the component (column 2) code to unbundle and demonstrate medical necessity, she says. Be sure to have documentation backing up your claim.

CCI 18.2 has also determined that several codes are mutually exclusive with 65778 and 65779:

• 65710 -- Keratoplasty (corneal transplant); anterior lamellar
• 65730 -- ... penetrating (except in aphakia or pseudophakia)
• 65750 -- ... penetrating (in aphakia)
• 65755 -- ... penetrating (in pseudophakia)
• 65756 -- ... endothelial
• 65781 -- Ocular surface reconstruction; limbal stem cell allograft (e.g., cadaveric or living donor)
• 65782 -- ... limbal conjunctival autograft (includes obtaining graft).

What this means: In a mutually exclusive bundle, CCI has determined that the two codes could not reasonably be performed together. If you report two mutually exclusive codes together, Medicare payers will only reimburse you for the lowest-paying procedure.

These mutually exclusive edits are also marked with modifier indicator "1," allowing separate reporting under appropriate circumstances and with a proper modifier.

More to come? "We are likely to see more and more of these bundling edits," says Mac. "It sometimes takes awhile for new codes to be reviewed and bundling edits to be fully determined, but these two codes were immediately designated in the first quarter of 2011 as bundled with many other services. The codes have low work RVUs associated with them, which suggests to me that they are considered part of a more comprehensive procedure and would not be paid separately. In other bundles, the procedural service is similar in essence to 65778 and 65779, and it makes sense that both services would not be performed at the same time on the same eye."

Watch These Transluminal Dilation Bundles

CCI 18.2 also introduces new bundles for two other codes introduced in 2011: 66174 (Transluminal dilation of aqueous outflow canal; without retention of device or stent) and 66175 (... with retention of device or stent).

What it is: Ophthalmologists can perform transluminal dilation as an alternative to traditional glaucoma treatments, such as trabeculectomy, to relieve the intraocular pressure through the aqueous outflow canal. In this procedure, the ophthalmologist makes a subconjunctival incision to expose the sclera, and creates a sclera flap above the level of the ciliary body. He then further dissects the sclera flap to expose Descemet's membrane and injects balanced salt solution is injected in the ostia of the canal for dilation. After achieving paracentesis of the anterior chamber, he then further expands the canal and inserts a viscoelastic material through the catheter into the canal. The catheter is removed. The ophthalmologist may place a stent within the canal to enhance aqueous flow through the trabecular meshwork.

As of July 1, CCI considers these procedures to be bundled into transluminal dilation:

• 65800 -- Paracentesis of anterior chamber of eye (separate procedure); with diagnostic aspiration of aqueous
• 65805 -- ... with therapeutic release of aqueous
• 65810 -- ... with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection
• 65815 -- ... with removal of blood, with or without irrigation and/or air injection
• 65860 -- Severing adhesions of anterior segment, laser technique (separate procedure)
• 66020 -- Injection, anterior chamber of eye (separate procedure); air or liquid
• 66030 -- ... medication
• 66500 -- Iridotomy by stab incision (separate procedure); except transfixion
• 66505 -- ... with transfixion as for iris bombe
• 66625 -- Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure)
• 66630 -- ... sector for glaucoma (separate procedure)
• 66635 -- ... optical (separate procedure)
• 66682 -- Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (e.g., McCannel suture)
• 67250 -- Scleral reinforcement (separate procedure); without graft
• 67255 -- ... with graft
• 92018-92019 -- Ophthalmological examination and evaluation, under general anesthesia ...

As with the bundles affecting 65778 and 65779, these bundles are marked with modifier indicator "1."

Learn more: For the complete set of CCI edits, visit www.cms.gov/NationalCorrectCodInitEd -- or search for bundles affecting individual codes at https://www.aapc.com/codes/.