Ophthalmology and Optometry Coding Alert

The latest version of the national Correct Coding Initiative (CCI), valid Oct. 1 to Dec. 30, 2002, can be summed up as one small step for coders, one giant leap for CMS' standard of care.

The Centers for Medicare and Medicaid Services reasons that once a "lesser" procedure is a regular and generally accepted part of a more extensive procedure it becomes the standard of care and is therefore incidental ... and not separately payable.

Version 8.3 of the CCI edits has the bundles to prove that CMS considers many injections, infusions, catheterizations and imaging procedures incidental-to the vast majority of surgical specialty procedures (see "CCI 8.3 Bundles Barely Budge Ophthalmology Coding Practices").

But these edits shouldn't have much of an effect on ophthalmology coding because they typically do not inject, says Michael J. Yaros, MD, a practicing ophthalmologist based in Runnemede, N.J. When they do inject, they are most likely to use injection codes for chalazions, steroid or cystoid macular edema, diabetic retinopathy, and chamber reform, none of which require the use of the newly bundled injection codes. He says that 67500* (Retrobulbar injection; medication [separate procedure, does not include supply of medication]) and 67505 ( alcohol) are used as anesthetic and for ocular pain in a blind eye, respectively, but only rarely. "For almost all of these, except possibly to reform a chamber, or endophthalmitis, the treatment is nonemergency and the patient can be brought back on a different day," he says.

One new edit that will affect ophthalmology coding is the bundling of the conjunctivoplasty codes 68320, 68326 and 68328 into the ectropion repair codes 67916 (Repair of ectropion; blepharoplasty, excision tarsal wedge) and 67917 (Repair of ectropion; blepharoplasty, extensive [e.g., Kuhnt-Szymanowski or tarsal strip operations).

One expert hypothesizes that CCI created the ectropion repair bundle to prohibit the coding and billing of the placement of stitches, a medial spindle, in the conjunctiva to help rotate an eyelid inward when an ectropion repair for a floppy, outward-facing lower eyelid is performed. "For a standard ectropion repair, you don't need to perform a medial procedure," an explanation for why some ophthalmologists may have perceived the two as separately billable in the past, says Hugh Cooper, MD, a practicing ophthalmologist in South Bridge, Mass. But as of Oct. 1, billing these two procedures separately will be no more.

All of these edits include a status modifier of 1, meaning the code pairs may be unbundled with modifier -59 (Distinct procedural service) under the appropriate circumstance when the requirements for unbundling are met.

The CCI edits also designate code pairs as mutually exclusive, those services/procedures that cannot reasonably be done in the same session.
For example, if an organ can be repaired by two difference methods, those two methods can't be used or reported together.

For instance, 65772 (Corneal relaxing incision for correction of surgically induced astigmatism) can't be reported with 66250 (Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure) because CCI has indicated that the two procedures are mutually exclusive of one another.

Per CCI instructions, mutually exclusive codes are not bundled. However, they are not to be billed together due to conflicting CPT definitions for the two codes or the "medical impossibility/improbability that the procedures could be performed at the same session." When codes identified as mutually exclusive are reported for the same patient encounter, generally only the lesser-valued procedure will be recognized and reimbursed.

Version 8.3 contains no additions or deletions to the mutually exclusive code category that will affect ophthalmology coding.