Ophthalmology and Optometry Coding Alert

CCI version 7.1 includes three sets of bundles that affect ophthalmologists. One set of the edits, which took effect April 1, should get the attention of all ophthalmologists and optometrists: It bundles punctal dilation (68801*) with plug closures (68761). The other two sets affect subspecialists in oculoplastics or neuro-ophthamology. One set bundles six muscle recession or resection codes and orbitotomy codes (67311, 67312, 67400, 67405, 67440 and 67450) into optic nerve decompression (67570), and the other set bundles eight orbitotomy codes (67400, 67405, 67413, 67414 and 67430-67450) into 10 orbital fracture repair codes (21385-21408).

Punctal Plugs Bundle

The new CCI edits bundle component code 68801* (dilation of lacrimal punctum, with or without irrigation) with comprehensive code 68761 (closure of the lacrimal punctum; by plug, each). Medicare will no longer pay for both dilation and closure because you cant place a plug without first dilating the punctum. Ophthalmologists and optometrists should not have been billing these codes separately anyway, says Michael X. Repka, MD, who is the American Academy of Ophthalmologys representative to the CPT advisory committee. If you need to perform a part of a procedure (in this case, dilation) to perform the rest of the procedure (plug closure), you cannot separate the two procedures for billing purposes.

Ophthalmologists perform dilation (68801*) and plug closure (68761) for two different reasons. Dilation is typically performed to clear an obstruction and open the punctum, while plug closure is to close it, says Raequell Duran, president of Practice Solutions, a coding and reimbursement consultancy based in Santa Barbara, Calif. A plug is inserted to keep the eye from making too many tears. The excess tearing occurs, paradoxically, in patients with a condition known as dry eye. The eye manufactures excess tears to counteract the dry eye. Dilation is performed when the punctum is blocked and the tears are unable to drain through the nasal lacrimal duct. Dilation may clear the obstruction.

Optic Nerve Decompression Bundle

The new CCI edits also bundle 67311 (strabismus surgery, recession or resection procedure; one horizontal muscle), 67312 (... two horizontal muscles), 67400 (orbitotomy without bone flap [frontal or transconjunctival approach]; for exploration, with or without biopsy), 67405 (... with drainage only), 67440 (orbitotomy with bone flap or window, lateral approach [e.g., Kroenlein]; with drainage) and 67450 (... for exploration, with or without biopsy) into 67570 (optic nerve decompression [e.g., incision or fenestration of optic nerve sheath]). These six procedures are an integral part of optic nerve decompression (67570) because you cant perform the decompression without them.

Ophthalmologists, mainly in oculoplastics and neuro-ophthalmology, who perform optic nerve decompression must move the muscle aside and explore the area to decompress the nerve, therefore they should not bill the strabismus codes (67311 and 67312) with 67570. They also have to perform the exploratory orbitotomy procedures (67400, 67405, 67440 and 67450) to perform the optic nerve decompression, which cannot be accomplished without the opening into the orbital space.

Orbital Fracture Bundle

A large series of bundles will also affect subspecialists in oculoplastics and neuro-ophthalmology who perform blowout orbital floor fracture and ordinary orbital floor fracture procedures. This series bundles all eight orbitotomy codes (67400, 67405, 67413, 67414 and 67430-67450) for exploration, excision and decompression into each of the 10 fracture repair codes (21385-21408). Many doctors doing these procedures have traditionally coded them separately, says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. The extensive work of the fracture repair dictates that the orbitotomy procedures are included.