Ophthalmology and Optometry Coding Alert

Re-repairs are uncommon, but they happen. Candidates often have a detached retina (67107-67112) and have another detachment within the global period. Retinologists tend to see this problem more than general ophthalmologists.
 
If the re-repair is related to the original procedure, bill the code again with modifier -78 (return to the operating room for a related procedure during the postoperative period) appended, says Karla Philippou, RHIT, CCS, CCS-P, CPC, CHCC, of Magnuson Medical Services, a healthcare consulting company based in Clearwater, Fla.
 
If the re-repair is unrelated to the original procedure, coding becomes more complicated. "I would use modifier -79 (unrelated procedure or service by the same physician during the postoperative period), as well as modifier -59 (distinct procedural service)," Philippou says, "because the diagnosis will be the same."
 
Another option is to use modifier -58 (staged or related procedure or service by the same physician during the postoperative period) if the second procedure was more involved than the initial one, says Raequell Duran, president of Practice Solutions, an ophthalmology coding and reimbursement consultancy based in Santa Barbara, Calif. If the second procedure isn't more involved, bill it with modifier -58 appended, Duran says. For example, the first repair is billed as 67105 (repair of retinal detachment, one or more sessions; photocoagulation, with or without drainage of subretinal fluid), and the second procedure is billed as 67107 (repair of retinal detachment; scleral buckling [such as lamellar scleral dissection, imbrication or encircling procedure], with or without implant, with or without cryotherapy, photocoagulation, and drainage of subretinal fluid). If the second procedure is more involved than the first and meets one of the three criteria for using modifier -58, code the second procedure as 67107-58.
 
Note: Modifier -58 requires that the procedure performed within the global either be 1. staged or planned prospectively, 2. more extensive than the original procedure, or 3. therapeutic following a diagnostic procedure.

The surgeon might be able to bill the procedure by appending modifier -59, says Lise Roberts, vice president of Health Care Compliance Strategies, a company that develops interactive compliance training courses based in Jericho, N.Y. Sometimes, the subsequent detachment is not due to the original procedure failing. The detachments are caused by the disease, rather than being a surgical complication. In fact, the second detachment can occur in a different location from the first even though it's in the same eye.
 
"If the new detachment is in a different place, I'd definitely drop the claim to paper and send it in with notes saying it's in a different place," says John Bell, chief executive officer of Maine Eye Care in Waterville. He would append modifier -59.
 
Most carriers cover a retinal re-repair appending modifier -58, -78 or -79 modifier -59 is unnecessary.

Code 67112 (... by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair[s] using scleral ipsilateral retinal detachment repair[s] using scleral buckling or vitrectomy techniques) is not recommended because the relative value units have not been updated to reflect the work that has been performed in these cases, Roberts explains. The work is always more extensive than the initial procedure work, and 67112 has a lower value than the other appropriate codes in that range. Payers, including Medicare, allow use of the other detachment-repair codes, as long as they are supported by medical documentation.