Ophthalmology and Optometry Coding Alert

If you're not using fifth-digit diagnosis codes to support glaucoma surgery, it shouldn't surprise you when Medicare pulls an Elvis with your next trabeculoplasty claim and returns it to sender. And fifth-digit coding is only a first step to obtaining maximum ethical reimbursement for glaucoma surgeries.

The 2002 Medicare glaucoma screening benefit has ophthalmology coders bombarded with tips on how to correctly code Medicare patients' screenings (see "Know When to Use Glaucoma Screening Codes Versus E/M or Eye Codes" in the April 2002 issue and "News Brief: CCI 8.0 Includes Eyelid Reconstruction, Screening" in the February 2002 issue of Ophthalmology Coding Alert), but coders may be wondering how to code glaucoma surgical procedures for those patients discovered to be in the advanced stages of the disease. But you can accurately code glaucoma surgery from start to finish if you follow these three easy steps.

When diagnosis coding for glaucoma, "it is imperative we go to the fifth digit to get the best reimbursement," says Fiona Lange, CPC, with Danbury Eye Physicians, a nine-physician multi-specialty practice in Danbury, Conn.

Fifth-digit coding also maximizes the chance you will be paid with the first claim. You must use the fifth digit for glaucoma diagnoses or "Medicare will send [a claim] back as unprocessable," according to Tracy M. Trout, CPC, coding specialist for Apple Hill Eye Center in York, Pa. Medicare's clean-claim requirements demand that you code to the highest level of specificity.

"Because most cases we see, especially surgically, are chronic problems with complications associated [with glaucoma], you need to be absolutely specific all the way because some of the complications are not necessarily normal post-op," Lange says. "If we're trying to rebill for other surgeries, more extensive surgeries after the fact, then we absolutely do need to make sure we are as specific as possible."

Even when the ophthalmologist is seeing a patient who is a "glaucoma suspect," you have fifth-digit-specific coding options for signs and symptoms diagnosis coding that payers are more likely to reimburse you for than if you use 365.00 (Preglaucoma, unspecified). These preferred codes include 365.01 (Open angle with borderline findings), 365.02 (Anatomical narrow angle), 365.03 (Steroid responders) and 365.04 (Ocular hypertension).

After the ophthalmologist makes a definitive diagnosis, you should use an even more specific diagnosis code. Ophthalmologists have a smorgasbord of primary diagnosis codes that constitute medical necessity for glaucoma: 365.11-365.9.

Avoid using less specific codes like 365.10 (Open-angle glaucoma, unspecified). Patients with advanced glaucoma require frequent visits to the ophthalmologist, and unspecified codes like 365.10 don't always make the grade as grounds for medical necessity when insurers examine claims.

The three most commonly used glaucoma surgery codes are 65855, 66625 and 66170. You should use 65855 (Trabeculoplasty by laser surgery, one or more sessions [defined treatment series]) when the patient treated has the most common type of glaucoma (diagnosis codes 365.11-365.15). 65855 designates argon laser trabeculoplasty, a procedure in which the eye pressure is lowered by increasing the fluid outflow using a laser spot on the eye's drainage mechanism.

66625 (Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma [separate procedure]) is a second laser surgery code for glaucoma that you should use in conjunction with a diagnosis of narrow angle glaucoma (ICD-9 codes 365.21-365.22). Use 66625 for peripheral iridectomies that are documented as a widening of the drainage area by lasering a tiny hole in the iris to reduce the patient's eye pressure.

An alternative to laser surgery, 66170 (Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery) is one form of filtration surgery  a trabeculectomy  that uses a small incision in the eye and a flap of tissue covering the incision to allow a slow release of fluid from the eye to the outer layers. Code this incisional approach and other similar filtering procedures with 66170.

When you bill Medicare for new glaucoma procedures, you have two options that may spare you a claim denial: You can use the unlisted-procedure code, 66999 (Unlisted procedure, anterior segment of eye), or as some coders suggest, you can use a code for a procedure that is similar in technique and work values.

Lange avoids using the unlisted-procedure code "because of the difficulties getting this paid." And she stresses the importance of an extremely well-documented operative report for coders attempting to get reimbursed for 66999.

But coders should also be wary of using a code for a procedure that is similar in technique and work values because unless you are performing the procedures yourself, it is almost impossible to know the complexity of the procedures. If you use this method, definitely discuss your options with the physician when determining a procedure that is similar in technique and work values to the procedure he or she performed.

Just when you think the worst is over, you still have follow-up procedures to code. Regardless of the surgical method your physician uses, glaucoma surgery patients will likely be back in the office even after the postoperative period expires so the ophthalmologist can closely monitor the progress of their eyes.

Practitioners differ on how to code certain types of visits and what code ranges to use - E/M or eye codes - because both sets of codes are acceptable as long as they accurately depict the service rendered.

Marcia Porter, CPC, CHCC, who codes for an ophthalmology practice in Charleston, S.C., says she codes follow-up visits like this: