Ophthalmology and Optometry Coding Alert

Ophthalmologists often perform epiretinal membrane stripping at the same time as retinal detachment repair. But often they dont receive proper reimbursement for both procedures. Using the correct modifier can solve this problem.

Epiretinal membrane stripping (67038) can be done separately from retinal detachment repair (67108), but it also can be done at the same time. When done at the same time, the epiretinal membrane stripping should be the primary procedure, with retinal detachment repair being second. This is because 67038 has a higher Relative Value Unit than any of the retinal detachment repair codes, and thus your reimbursement would be higher.

Tip: The only retinal detachment repair code not bundled by the Correct Coding Initiative (CCI) into 67038 is 67108.

You cannot get paid in full for both procedures when performed at the same time unless they are completely unrelated, our sources explain. Correct coding includes the usage of modifier -51 (multiple procedures) with 67108 (repair of retinal detachment; scleral buckling [such as lamellar scleral dissection, imbrication or encircling procedure], with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique). Accordingly, you would be paid only half.

And if you bill the full amount, Medicare will reduce the second one by half anyway, says Kitty Timmes, COMT, office manager for Joseph J. Timmes Jr., MD, FACS, a retinologist practicing in Annandale, VA.

There are several different scenarios that apply to the use of these codes, says Timmes.

An epiretinal membrane, which she describes as a wrinkle in the retina, may require no treatment at all. At the time that it becomes larger or troublesome to the patient, thats when the physician says we have the option of operating and trying to remove the membrane, she says. It depends on the vision of the patientthere are no guidelines on clinical findings required to show medical necessity from Medicare for 67038. If all the physician did was the epiretinal membrane stripping, he or she would bill 67038 alone.

Sometimes a patient has an epiretinal membrane that has been there for some time, and also develops a retinal detachment. In this case, you would bill for both an epiretinal membrane stripping and a retinal detachment repair. Since these services are not bundled, the only modifier you need is the multiple procedure modifier, -51.

Code 67038 During Post-op Period
of Detachment Repair

One situation in which the ophthalmologist could be paid 100 percent for both, using modifier -58 (staged or related procedure or service by the same physician during the postoperative period), occurs when the patient has a retinal detachment and the [...]