Ophthalmology and Optometry Coding Alert

The Correct Coding Initiative 8.2 edits have arrived, and while the number of new bundles may be overwhelming, savvy coders who know the rules for modifier -59 will be able to garner full reimbursement. Modifier -59 (Distinct procedural service) applies only to specific circumstances in which a procedure that would normally be bundled with another procedure should not be bundled for any of the following reasons: It was performed in a separate surgical session or patient encounter from the procedure(s) with which it would normally be bundled. It was a different procedure or surgery from the one with which it would normally be bundled. (Note: This must be medically necessary as indicated by different diagnosis codes.) It was done in a different site or organ system. It was done in a separate incision or excision. It was a separate lesion. It was a separate injury not ordinarily encountered or performed on the same day by the same physician. The CCI edits use three indicators 0, 1 and 9 to reflect whether or not the use of CPT modifier -59 with otherwise bundled codes is appropriate. 0 specifies that no circumstances exist in which appending modifier -59 is appropriate; 1 stipulates that a -59 modifier is allowed because the code that would normally be bundled is distinct or independent from the other services provided that day; 9 indicates there no longer exists a bundling between the specified codes deletion effective the same date as the CCI edits' effective date.

With respect to the new comprehensive/component codes that can be unbundled due to indicator 1, "these procedures usually are included and only rarely are they unbundled with the appropriate modifier," says Michael X. Repka, MD, AAO representative to the American Medical Association's CPT advisory committee. New 1 indicator comprehensive/component codes: Graft codes 20900-20936 are now included in reconstruction codes 21172, 21175 and 21180. Bone graft codes 20900 and 20902 are also included in reconstruction codes 21182-21184 and fracture treatment using bone graft codes 21395 and 21408. 21280 (medial canthopexy) and 21282 (lateral canthopexy) are now included in 67924 (extensive blepharoplasty) and eyelid reconstruction codes 67971 and 67973-67975. 21280 now includes 67715, canthotomy; 21282 now includes tarsorrhaphy codes 67880 and 67882. 67950 (canthoplasty) now includes tarsorrhaphy code 67882; also, 67950 is now included in eyelid reconstruction codes 67971 and 67975. Be aware that there are an extraordinary number of codes that now include anesthesia code 01995 (Regional intravenous administration of local anesthetic agent or other medication [upper or lower extremity]) that can be unbundled in certain circumstances. New comprehensive codes that can't be unbundled due to the 0 indicator: Eye codes 92002-92014 now include health and behavior assessment/intervention codes 96150-96155. You should also [...]