Ophthalmology and Optometry Coding Alert

Coders have been back and forth over the rules for billing iridectomies, trabeculectomies, and anterior vitrectomies when performed in conjunction with cataract removals, but the latest Correct Coding Initiative (CCI) edits reassure coders that, under the appropriate circumstances, these three procedures are separately billable. The CCI 8.2 edits are effective July1 through Sept. 30. A three-step method will help you avoid claims denials:

Step 1: Diagnose the cataract(s) to the highest degree of specificity possible. Be sure to code to the fifth digit (366.xx). For example, an anterior subcapsular polar senile cataract corresponds to 366.13. "Medicare does not like to pay for .9 DXs," warns Melissa K. Duchak, CPC, an ophthalmology coding consultant based in Sinking Spring, Penn. "They are too 'generic' [Medicare feels] the doctor should know more about the patient than 'unspecified.' " That's correct, Duchak notes, the carriers are right; the physicians know the exact type of cataract the patient has. Step 2: Determine a separate diagnosis code that accurately describes the medically necessary procedure that is unrelated to the cataract removal diagnosis code.

For example, a trabeculectomy is performed at the same time as a cataract extraction and it is medically necessary to control elevated intraocular pressure from glaucoma. Therefore, you should use diagnosis code 365.xx for the glaucoma and the appropriate 366.xx diagnosis code for the cataract. Step 3: Confirm that the medical record clearly documents the medical necessity of the procedure that is going to be separately reported.

Assuming the separate diagnosis code suffices as justification for the separate procedure that is to be performed could end in denied claims. If, as in the case of a trabeculectomy, the corresponding diagnosis code lists a form of glaucoma that is not surgically treatable (i.e., residual stages of glaucoma, 365.15, 365.24 or 365.32), your claim will be denied even though there is a separate diagnosis.

When considering coding iridectomy, trabeculectomy, and anterior vitrectomy as separate procedures, ask yourself the following: Can the iridectomy be considered an integral part of the procedure? Is the trabeculectomy being performed as a preventive service to head off a possible transient increase in intraocular pressure postoperatively? Is there no evidence for glaucoma preceding the cataract surgery? Are you coding the vitrectomy because of vitreous loss that occurred during "routine" cataract extraction? If you answer "yes" to any of these questions, the procedure is not separately billable. If you do determine a procedure to be separately billable, you may identify the procedure as a "distinct procedural service" by appending modifier -59 to the separate procedure's CPT code. Modifier -59 alerts the payer's payment processing system that separate payment for the procedure is indicated and should not be denied as a bundled service. [...]