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 doctor performs successful surgery using a scleral buckle procedure (67107). But for some reason, an epiretinal membrane starts forming after the procedure. It pulls on the retina, causing a traction detachment, says Timmes. That causes a recurrent detachment, and the patient has to go back to the
operating room.

This is a scenario in which a greater procedure follows a lesser one, so modifier -58 applies. The vitrectomy with epiretinal membrane stripping is coded as 67038-58 (vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping) in the primary position, and the retinal detachment repair typically is coded as 67108-51 in the secondary position.

Correct Usage of Modifier -51

Getting paid more than half for the retinal detachment repair is difficult when performed with epiretinal membrane stripping, says Joseph Velasco, billing manager for Cornell Ophthalmology Associates, a nine-ophthalmologist, two-retinologist university practice in New York City. Im seeing a pattern here of Medicare paying half for the detachment.

For example, in one case, a doctor performed 67108 and 67038. There were three diagnoses used for 67108 (retinal detachment repair), which had the -51 modifier: 361.00 (retinal detachment with retinal defect, unspecified), 361.03 (recent detachment, partial, with giant tear), and 379.03 (anterior scleritis). For 67038, the retinologist used diagnosis codes 379.23 (vitreous hemorrhage), 361.03 (recent detachment, partial, with giant tear) and 361.00 (retinal detachment with retinal defect, unspecified). Obviously, the two procedures were related: Both shared some of the same diagnosis codes (although the primary diagnosis for the epiretinal membrane stripping was quite different from the primary diagnosis for the retinal detachment repair).

The multiple procedure payment rule applies when two or more procedures are performed on the same eye in the same surgical session. This rule requires the use of modifier -51 on all secondary procedure codes and results in half of the normal Medicare fee schedule allowance for all codes not considered bundled into the primary procedure code.

Another scenario illustrates how three procedures can be bundled by Medicare into one, leaving you with only one payment. One retina specialist at Velascos practice performed 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, drainage of subretinal fluid) at the same time that he did a 67040 (vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation) and a 66920 (removal of lens material; intracapsular).

The diagnosis codes for the first two procedures were 361.07 (retinal detachments and defects; old detachment, total or subtotal) and 379.23 (disorders of vitreous body; vitreous hemorrhage); the diagnosis code for the third was 379.34 (posterior dislocation of lens).

Medicare allowed full payment for the 67107 but considered the 67040 bundled into that procedure. This is because 67040 is listed as a component code of 67107 in the Correct Coding Initiative, which means they are always bundled unless there is a reason for them to be considered distinct and separate procedures.

As for the 66920, Medicare refused to cover it all, because it was performed in an office setting. Im not appealing these, because it was in the same eye, says Velasco. If somethings bundled, its bundled. When you have something straightforward like thatits in the CCItheres nothing you can do.

In fact, Velasco concedes that modifier -59 can help to break some of these bundles, but he questions whether its worth using it. Even if they do pay, if they do an audit, theyll ask for the money back and we could end up with fines and penalties as well, he says.