Ophthalmology and Optometry Coding Alert

Reviewed May 18, 2015

Integumentary codes or eyelid excision code? Picking the wrong one could cost you more than $500

When an ophthalmologist removes lesions from a patient's eyelids, the coder is faced with a classic dilemma. Is it purely an integumentary procedure, reported with a code from the 1144x series (Excision, other benign lesion including margins except skin tags [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane) - or is it an eyelid surgery procedure, 67840 (Excision of lesion of eyelid [except chalazion] without closure or with simple direct closure)?

The answer, and the path to accurate and profitable coding, depends on the number, location, type and size of the lesions. Following are several real-life coding scenarios to help you make the right choice next time.

Don't forget: Check with your carriers to see which modifiers they need to see when you're reporting multiple lesion removals, says Paulette Aaronson, CPC, senior coder for Ophthalmic Consultants of Boston. Depending on the carrier, you may need to append an eyelid modifier (-E1, Upper left, eyelid; -E2, Lower left, eyelid; -E3, Upper right, eyelid; or -E4, Lower right, eyelid) or modifier -51 (Multiple procedures) - or perhaps even both.

Scenario 1: 1 Lesion, 1 Eyelid

The ophthalmologist removes one lesion from the upper left eyelid. The excised skin measures 0.8 cm in diameter, and the pathology report shows that it's benign.

Coding: Code 67840 not only accurately describes the ophthalmologist's work but also brings more reimbursement than the applicable skin code, 11441 (... excised diameter 0.6 to 1.0 cm). Code 67840's 7.75 RVUs will bring $277.10 to a nonfacility, over $100 more than 11441 (4.48 RVUs x 35.7547 conversion factor = $170.19). The pricing for 67840 takes into account the difficulty of working around the eye compared to other parts of the body.

Key: To be able to report 67840, the ophthalmologist has to remove more than just skin, says Renee Adkins, CPC, administrative assistant and coder for the oculoplastics department at Minnesota Eye Associates in Bloomington. In the introduction to the eyelid excision codes, the CPT manual states that the codes include procedures ""involving lid margin, tarsus and/or palpebral conjunctiva.""

Scenario 2: 4 Lesions, 1 Eyelid

The ophthalmologist removes four benign lesions from the lower right eyelid. All of the lesions are less than 0.5 cm in diameter.

Coding: While 67840 would work here, 11440 (... excised diameter 0.5 cm or less) is a better choice. Since 67840 is an excision code, which is billed by the lid, you can't report it with units, Aaronson says - unlike the integumentary codes. Report 11440 on the first line and 11440-51 on the next three lines (appending modifier -E4 if necessary); even after the automatic reductions for multiple procedures, it's likely to bring in more reimbursement than reporting 67840 once.

Note: You cannot add the diameters of the lesions together to arrive at a higher-level code, Aaronson says. Two 0.4-cm-diameter lesions do not equal one 0.8-cm- diameter lesion. Report each lesion separately.

Scenario 3: 2 Lesions, 2 Eyelids

The ophthalmologist removes one benign lesion (0.4 cm) from the upper right eyelid, another (0.5 cm) from the lower right and one (0.5) from the lower left.

Coding: Since the lesions are each on different lids, you can code 67840 more than once, Aaronson says. Report codes 67840-E3, 67840-E4 and 67840-E2. Because the description of CPT code 67840 mentions nothing about size, the diameter of each lesion makes no difference in your coding or reimbursement.

Note: CPT codes 11441-11446 and 67840 all have 10 global days of postoperative care assigned to them. The preoperative, intraoperative and postoperative percentages of total payment assigned to these codes is 10, 80 and 10 percent, respectively.

Scenario 4: Malignant Lesion on Lid Margin

The ophthalmologist removes a basal cell carcinoma from the upper left eyelid. The cyst was on the lid margin, which the ophthalmologist repaired after the excision.

Coding: The correct code depends on how much of the margin was involved, Aaronson says. If it was less than one-fourth, use 67961 (Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin). If more than one-fourth, use 67966 (... over one-fourth of lid margin).

Scenario 5: 3 Malignant Lesions

The ophthalmologist removes three squamous cell carcinomas from the upper left eyelid. Each is more than 0.5 cm; each requires intermediate repair.

Coding: Report three units of 11641 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm). Measure the length of the intermediate repair on each site and add them together to pick a 1205x code (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes).

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