Ophthalmology and Optometry Coding Alert

Can't remember whether punctum closure has a 90- or 10-day global period? Don't be surprised, then, if your postoperative services reimbursements for this and other minor procedures come up short.

Coding minor procedures can be a perplexing task, given that minor procedures can have both 0- and 10-day global periods and there are complicated rules for appending modifier -25 to boot. But if you know how to identify minor procedures and you know when you can separately bill an office visit by appending modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), your next chalazion removal will be a piece of cake.

The first step to mastering minor procedures is to learn how to identify them. To many coders, this may seem like a no-brainer: The minor procedures are "starred," or followed by an asterisk, in the CPT manual & right? But watch out: If you use the starred procedures as the sole indicators of procedures classified as minor, you may be setting yourself up for inadequate reimbursement.

For example, suppose a patient presents with dry-eye syndrome, the decline of quantity or quality of tears that results in constant eye irritation and potential scarring or ulceration of the cornea. The physician decides to insert punctum plugs in the patient's left and right lacrimal ducts to prevent moisture from draining out of the eyes. Two weeks later the patient returns with plug-related discomfort in his left eye.

If the coder determined the initial procedure's global period strictly according to whether an asterisk followed the procedure, the coder missed out on reimbursement by assigning a 90-day global period to 68760 (Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery) - a procedure with a 10-day global period. The result: The coder mistakenly categorized the return visit as a procedure included in 68760's global surgical package simply because the procedure was not starred in the CPT manual.

To keep track of the procedures that are starred in CPT 2002, many ophthalmology offices use the same asterisks as CPT to indicate minor procedures on their route slips or superbills. "We have our most common procedures divided up into cornea, lid, and anything that is a starred procedure [in CPT] has an asterisk. Whoever is in with the doctor knows this is a starred procedure or this is not a starred procedure," says Erica Kuntz, CPC, coding specialist with Northeast Ohio Eye Surgeons in Kent, Ohio.

Although CPT 2002 considers minor procedures starred procedures, Medicare doesn't recognize this assertion, and more than half of the eye and ocular adnexa surgical procedures that have a 0-day or 10-day global period for Medicare are not starred. CPT guidelines also state that these starred procedures do not include any pre-or postoperative services, so they do not have any global follow-up days. But Medicare has different rules: Minor procedures that require an incision usually have a 10-day global period, which means coders must use global package modifiers like -25 to bill for significant and separately identifiable office visits.

The procedures in the above chart fall into the category of nonstarred procedures that Medicare considers "minor" (0-or 10-day global periods):

As for the procedures that aren't starred in CPT but that Medicare considers "minor," Kuntz relies on her general knowledge of the procedures and their complexity when she determines whether they are considered minor. According to Kuntz, "Everyone around here pretty much knows what has 90, what has 10, and what has 0 postoperative days." This general understanding of what makes a procedure minor and how one can recognize major procedures is extremely useful with the confusion surrounding the starred procedures.

For those coders who are not as sure of themselves when it comes to remembering global periods, Kuntz suggests they post a list of the post-op periods for the procedures most commonly used in their office so that the person who's with the doctor, the scribe, and the doctor can just take a quick look.

To make matters even more complicated, non-Medicare third-party payers (private carriers, HMOs) may assign their own global periods to these procedures. So be sure to check your local third-party payer's policies before coding a procedure, especially if you plan on using a modifier on the procedure's corresponding office visit code.