Ophthalmology and Optometry Coding Alert

Tip: Check modifier indicators for ability to report codes separately.

If you’re in the habit of reporting certain ocular injections separately along with paracentesis procedures, you need to pay attention to the latest set of Correct Coding Initiative edits.

According to CCI 20.1, effective April 1, 2014, these ocular injection procedures:

• 67515 (Injection of medication or other substance into Tenon’s capsule)
• 68200 (Subconjunctival injection)

are now included in these paracentesis procedures:

• 65800 (Paracentesis of anterior chamber of eye [separate procedure]; with removal of aqueous)
• 65810 (...with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection)
• 65815 (...with removal of blood, with or without irrigation and/or air injection).

Paracentesis — the drainage of fluid from the eye to balance the overall pressure — is usually performed if the central retinal artery is blocked. After numbing the eye, the ophthalmologist inserts a needle attached to a syringe into the anterior chamber of the eye to aspirate the necessary amount of watery substance (aqueous). Once the aqueous is aspirated, the pressure inside the eye is reduced and the central retinal artery is unblocked; thereby reducing the damage caused to the retina by the blockage. 

In these new CCI edits, CPT® codes 67515 and 68200 appear in Column 1, and 65800, 65810, and 65815 appear in Column 2 of the “Column 1/Column 2” table. According to CCI, a code in Column 2 is considered a component of the Column 1 (or “comprehensive”) code. If you report the two codes together, only one of them — the Column 1 code — is reimbursable by Medicare.

Exception: These codes are marked with modifier indicator 1, which signifies that the two codes in the edit pair can be reported together if the clinical circumstances are appropriate, and if a proper modifier — such as modifier 59 (Distinct procedural service) and/or RT (Right side) or LT (Left side) — is appended to the Column 2 code.

Example: If one procedure is done on one eye and the other on the other eye — for example, due to injuries sustained in a motor vehicle accident where there were multiple traumas — then the codes could be reported separately, suggests Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. 

Eye Exam Codes Now Include Visual Function Screening

Another new group of edits in CCI 20.1 establish that the codes ophthalmology coders use to describe eye exams:

• 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient)
• 92004 (...comprehensive, new patient, 1 or more visits) 
• 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient)
• 92014 (... comprehensive, established patient, 1 or more visits)

now include 99172 (Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision [may include all or some screening of the determination(s) for contrast sensitivity, vision under glare]). 

Unlike the above edits, CCI has marked these edits with modifier indicator “0,” which means that 99172 cannot be reported with 92002-92014 under any circumstances. If they are reported together, only the column 1 codes (92002-92014) will be reimbursed.

“I’m not surprised at this edit at all,” says Mac. “The eye exam usually includes all the components of the 99172 service, so it is a likely bundling edit.”

CPT® code 99172 was created for occupational medicine practitioners who needed a code for screening of pilots and other professionals. It is not frequently used by ophthalmologists, say experts.

However, “there may be times where an ophthalmologist would use the 99172 code for patients who need clearance for their jobs, recertifications or licensure to operate certain vehicles and machinery,” notes Mac. “It would probably be mandated by the employer or licensing/recertification board and covered only by private payers or employers or could even be an out-of-pocket expense for the patient.”

Watch for New Biopsy, Excision Bundles

Among the Mutually Exclusive edits in CCI 20.1, you will find these new additions:

• 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion)
• 11310 (Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less)
• 11311 (...lesion diameter 0.6 to 1.0 cm)
• 11312 (...lesion diameter 1.1 to 2.0 cm)
• 11313 (...lesion diameter over 2.0 cm)

are now mutually exclusive with 67810 (Incisional biopsy of eyelid skin including lid margin).

Unlike the Column 1/Column 2 edits, in which CCI determines that one procedure is an intrinsic part of another, the Mutually Exclusive edits are pairs of codes that could not or would not be performed at the same session for the same patient. 

Also unlike the Column 1/Column 2 edits, in which Medicare will reimburse only the Column 1 code if the two codes are reported together, in a Mutually Exclusive pair, Medicare will only reimburse the lesser-valued of the two codes.

The new 67810 edits are marked with modifier indicator 1, allowing separate reporting under appropriate circumstances.

Additionally, CPT® code 17311 (Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain[s] [e.g., hematoxylin and eosin, toluidine blue], head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks) is now a mutually exclusive procedure with:

• 67840 (Excision of lesion of eyelid [except chalazion] without closure or with simple direct closure)
• 67961 (Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin)
• 67966 (...over one-fourth of lid margin).

However: Since Mohs surgery is generally not done by ophthalmologists, ophthalmology coders should not be too concerned with this edit. This is work performed by a dermatologist with Mohs surgery training, clarifies Mac.