Ophthalmology and Optometry Coding Alert

Tip: Code the diabetes first, then the manifestation.

Does your DR coding knowledge stand the test? Read on for the answers to our coding quiz.

Answer 1:B. ICD-9 guidelines direct you to “code first diabetes.” Report the proper code for the underlying condition (diabetes with ophthalmic condition) as the primary diagnosis. Which code you report depends on the type of diabetes, and whether it’s controlled or uncontrolled:

• 250.50 — Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled
  
• 250.51 — …type I [ juvenile type], not stated as uncontrolled
  
• 250.52 — … type II or unspecified type, uncontrolled
  
• 250.53 — … type I [ juvenile type], uncontrolled.
  

“Do not take into consideration the patient’s age when diabetes was diagnosed or the fact that the patient takes insulin” when making your diabetes code selection, cautions Sharon Molinari, RN, HCS-D, HCS-O, a home health consultant based in Henderson, Nev. “Taking insulin does not make a diabetic patient ‘insulin-dependent’ or Type I.”

As a secondary diagnosis, you would then code the manifestation. For DR, the ICD-9 codes include:

• 362.01 — Background diabetic retinopathy
  
• 362.02 — Proliferative diabetic retinopathy
  
• 362.03 — Nonproliferative diabetic retinopathy NOS
  
• 362.04 — Mild nonproliferative diabetic retinopathy
  
• 362.05 — Moderate nonproliferative diabetic retinopathy
  
• 362.06 — Severe nonproliferative diabetic retinopathy
  
• 362.07 — Diabetic macular edema.
  

In this scenario (proliferative DR as a result of uncontrolled type II diabetes), the primary diagnosis would be 250.52 and the secondary diagnosis would be 362.02.

Answer 2: A. DR patients are usually facing a series of laser treatments, with either a focal laser (67210, Destruction of localized lesion of retina [e.g., macular edema, tumors], 1 or more sessions; photocoagulation) or panretinal photocoagulation (PRP) (67228, Treatment of extensive or progressive retinopathy, 1 or more sessions; [e.g., diabetic retinopathy], photocoagulation), also known as “scatter treatment.” 

Background — or nonproliferative — diabetic retinopathy (BDR or NPDR) is represented by ICD-9 code 362.01 (Background diabetic retinopathy). Although BDR may never require treatment, in severe cases ophthalmologists use a focal laser (67210) to treat areas of edema resulting from leaking blood vessels. Using a grid pattern, the focal laser aims directly at the leaky sites to seal them off.

However: In most cases, the ophthalmologist is treating the edema, not the diabetes. Link 67210 to ICD-9 code 362.83 (Other retinal disorders; retinal edema) instead of 362.01.

In cases of proliferative diabetic retinopathy (362.02), instead of using the focal laser to seal off one site at a time, ophthalmologists would use PRP (67228) to target the entire retinal area. 

Answer 3: D. Although BDR and PDR occur often in both eyes, the treatments for these conditions are inherently unilateral. If the ophthalmologist treats only one eye, report the laser code only once. But when the ophthalmologist treats both eyes during one session, report the laser code twice, either on one line (67210-50) or two lines (67210-RT, 67210-50-LT), for example, depending on the payer’s preference.

Medicare has assigned both 67210 and 67228 a bilateral status of “1,” meaning that if you report them bilaterally, carriers will reimburse 150 percent of the fee schedule amount for a single code (or your total actual charge for both sides, if it’s lower). For example, in 2014, payment for a bilateral PRP performed in an office setting would be 150 percent of Medicare’s fee schedule amount for a single 67228 ($1051.40), leading to approximately $1500 in reimbursement.

Answer 4: D. Subsequent treatments of 67210 or 67228 on the same eye within the 90-day global surgical period are not separately billable, due to the “one or more sessions” verbiage in the code description.

However: When a subsequent treatment within the postoperative period is in a different eye, you should code and bill this service with modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period).

In this scenario, if the patient returns a month after an initial treatment with 67210 of the left eye, and the physician notices that the right eye has developed retinal edema and performs focal laser treatment in that eye, you would report 67210-79-RT. Modifier 79 indicates that this procedure is unrelated to the first procedure; the diagnosis and treatment are the same, but the eye is different.

Opportunity: Each line item should get modifier 79 if the surgeon performs more than one unrelated procedure.

Don’t miss: As is the case with modifier 79, the eye modifiers (LT and RT) are crucial. If modifier LT had not been used for the first procedure and modifiers 79 and RT used for the second procedure, the second procedure would look like an additional treatment on the same eye to Medicare and would be denied.