Ophthalmology and Optometry Coding Alert

If you're not 100 percent sure that you will choose the appropriate laser code the next time you're playing eeny-meeny-miny-mo with 67228 and 67210, use the selected diagnosis code to solidify your decision.

Determining when a situation requires 67228 (Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagu-lation [laser or xenon arc) instead of 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; photocoagulation) is a nightmare for most coders. But if you know the minor differences in what conditions these laser services treat, you'll have sweet dreams coding 67228 and 67210.

Rely on Your MD for 67228 and 67210 Dx Codes

Laser treatments 67228 and 67210 have a multitude of similarities, but if your ophthalmologist provides you with diagnoses of the utmost specificity, you will be able to determine which laser treatment was used.

Codes 67228 and 67210 are both treatments for retinal disorders that can result from diabetic retinopathy. But here's the difference: Code 67228 reflects treatment for proliferative diabetic retinopathy, 362.02, whereas 67210 is used to treat background diabetic retinopathy, 362.01, and macula edema, 362.83, says Sandra Zarowitz, coding specialist for the VMR Institute in Huntington Beach, Calif.

Background, or nonproliferative, diabetic retinopathy is the early stage of the disease, during which blood vessels in the retina begin to break and leak. In this early stage, patients are at a low risk for vision loss or blindness. Proliferative diabetic retinopathy, on the other hand, is more serious because the new blood vessels that form to replace those that have broken or leaked can cause scarring or bleeding in the vitreous humor. The differences in the laser treatments cater to the different stages of the retinopathy 67210 treats the lesions of fluid leakage and hemorrhaging in localized areas of the macular region, and 67228 treats the blood vessel growth outside the macular region covering a broader section, Zarowitz says.

Code Both Sessions of 67210 and 67228

CPT codes 67210 and 67228 are bundled according to the National Correct Coding Initiative (NCCI) edits which means you'd better have a good explanation for reporting both codes for one patient, Zarowitz says.

When codes are bundled by the NCCI Edits they can't both be billed when they are performed on the same day by the same surgeon. But a bundle doesn't mean 67210 and 67228 are never separately billable when performed for the same patient, Zarowitz says. She gives some examples of when you can and can't report both 67210 and 67228.

When 67210 and 67228 are performed on separate eyes. If a patient presents with background diabetic retinopathy in his left eye and proliferative diabetic retinopathy in his right eye, you will need to code 67210-LT and 67228-RT, which, under these circumstances, are separately billable.

When 67228 is performed in the postoperative period of 67210. Let's say a patient presents with diabetic macular edema in her right eye and is treated with 67210. Two weeks later the same patient returns with proliferative diabetic retinopathy and is treated with 67228. Because 67228 is considered a more extensive procedure than 67210, it is separately billable. You will need to append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to 67228.

When 67210 is performed in the postoperative period of 67228. When focal laser is performed on the same eye following panretinal photocoagulation, carriers aren't too thrilled to pay for the second service of 67210 due to the fact that PRPcan cause macular edema and the carrier doesn't want to pay for a laser treatment that was the result of another, thanks to the "one or more sessions" language included in the descriptors of laser treatments.