Ophthalmology and Optometry Coding Alert

If you were hoping to report anesthetic injections along with eye surgery codes and receive separate reimbursement, Medicare has bad news. The latest set of the Correct Coding Initiative (CCI) edits, version 14.3, leaves little doubt that Medicare is in the mood to bundle nerve blocks.

CCI 14.3, which takes effect for dates of service beginning Oct. 1, 2008, bundles 64402 (Injection, anesthetic agent; facial nerve) into 163 eye surgery codes, joining 96 bundles already in place. The result: Code 64402 is now bundled into nearly all of  the eye surgery codes, meaning that CCI considers 64402 to be an inherent part of  those procedures.

If you do report 64402 with an eye surgery code without modifiers, Medicare payers will only reimburse for the eye surgery code (the comprehensive code).

Exceptions: Corneal procedures 65760 (Keratomileusis), 65765 (Keratophakia), 65767 (Epikeratoplasty), and 65771 (Radial keratotomy) are not included in these edits.

Also excluded are unlisted-procedure codes 66999, 67299, 67399, 67599, 67999, 68399, and 68899; and add-on codes 66990, 67225, 67320, 67331, 67332, 67334, 67335, and 67340. But because you cannot report an add-on code without also reporting a primary code, and as most of the primary codes are now bundled with 64402, you also will not be able to report any of those add-on codes with 64402.

Nothing new: In 2003, CCI 9.0 bundled nerve block codes 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) into most of the eye surgery codes --" with the exceptions of the corneal procedures, unlisted procedures, and add-on codes mentioned above.

Why the exceptions? "It probably has to do with the reason why the facial nerve block is given and how the nerve block affects the muscles of the facial expression," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla. "Therefore, it is not likely that a nerve block would be used for the corneal procedures. That being said, I'm not sure why some of the other procedures would be included in the bundling edit."

Background: Medicare has previously come down hard on other drug infusions and injections. In 2006, CCI 12.0 bundled drug administration codes 90760 (Intravenous infusion, hydration; initial, 31 minutes to one hour), 90765 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to one hour), 90772 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), 90774 (... intravenous push, single or initial substance/drug), and 90775 (... each additional sequential intravenous push of a new substance/drug [list separately in addition to code for primary procedure]) into most of the eye surgery codes.

Most of these bundles carry modifier indicator "1," "which indicates there may be circumstances in which it would be acceptable to bill, and an acceptable modifier will bypass the edit," says Kelly Dennis, MBA, CPC, ACS-AP, with Perfect Office Solutions of Leesburg, Fla.

You can break the bundle and report the two procedures separately if it is medically necessary, meets the criteria for appropriate unbundling and separate reporting of bundled procedures, and is supported by your documentation, agrees Mac.

Add the appropriate modifier (such as 59, Distinct procedural service) to the nerve block or drug administration code (the component code).

CCI 14.3 has paired several vitrectomy procedures into mutually exclusive bundles, which means that practitioners would not usually perform the two bundled codes together. If you do report the two codes separately without modifiers, Medicare payers will only reimburse for one  of them.

Mark these edits: Code 67039 (Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation) is bundled into 67040 (... with endolaser panretinal photocoagulation), 67041 (... with removal of preretinal cellular membrane [e.g., macular pucker]), 67042 (...with removal of internal limiting membrane of retina [e.g., for repair of macular hole, diabetic macular edema], includes, if performed, intraocular tamponade [i.e., air, gas, or silicone oil]), and 67043 (...with removal of subretinal membrane [e.g., choroidal neovascularization], includes, if performed, intraocular tamponade [i.e., air, gas, or silicone oil] and laser photocoagulation).

A previous edit put 67039 into column 1 and 67040 into column 2 of a mutually exclusive bundle. CCI 14.3 deletes that bundle in favor of the new one, in which the codes switch columns. In a mutually exclusive bundle (as with a column 1/column 2 bundle), Medicare payers will only recognize the column 1 procedure if you report the two together without modifiers.

So, if you were to report 67040 and 67039 together without a modifier, you would only see reimbursement for the column 1 procedure, 67040.

Also, 67040 is now bundled into 67042 and 67043. Code 67041 is bundled into 67040, 67042, and 67043; and 67042 is bundled into 67043.

That's not all: Codes 67042 and 67043 now include 65810 (Paracentesis of anterior chamber of eye [separate procedure]; with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection), 67005 (Removal of vitreous, anterior approach [open sky technique or limbal incision]; partial removal), 67010 (... subtotal removal with mechanical vitrectomy), and 67027 (Implantation of intravitreal drug delivery system [e.g., ganciclovir implant], includes concomitant removal of vitreous).

Code 67027 is also now included as a component code in comprehensive codes 67039, 67040, 67042, and 67043. And 67113 (Repair of complex retinal detachment [e.g., proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees], with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens) now includes 67043. (As with 67039 and 67040, 67113 and 67043 are essentially swapping places --" CCI 14.3 deletes a previous bundle with 67043 in column 1 and 67113 in column 2.)

Deletions: CCI 14.3 deletes a few previous bundles that included 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch) in 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification], complex, requiring devices or techniques not generally used in routine cataract surgery [e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis] or performed on patients in the amblyogenic developmental stage), 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]), and 67113.

The new version of CCI also unbundles 67113 and anesthetic injection code 64405 (...greater occipital nerve).

Resource: Download a complete list of current CCI edits at www.cms.hhs.gov/NationalCorrectCodInitEd/.