Ophthalmology and Optometry Coding Alert

Choosing the correct laser code can be a nightmare for ophthalmology coders because of the similarities between 67228 and 67210. If you're relying on the diagnosis code to point you in the right direction, you could be setting yourself up for miscoding. Ensure you pick the right code every time with this expert advice.

Determining when a situation requires 67228 (Treatment of extensive or progressive retinopathy, one or more sessions; [e.g., diabetic retinopathy], photocoagulation) instead of 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; photocoagulation) isn't complicated if you know the differences between the procedures.

Laser treatments 67228 and 67210 have a multitude of similarities, but if your ophthalmologist provides documentation of the utmost specificity, you will be able to determine which laser treatment he used.

Code 67210 represents a focal or grid photocoagulation laser, whereas 67228 represents a panretinal (encompassing the entire retina) photocoagulation laser, says Byrd Evans, COE, OCS, senior consultant with Advantage Administration in Dallas.

Bottom line: The major difference between the two codes is that 67228 re-presents a procedure for treating vessels, and 67210 is for lesions or masses, says Becky Zellmer, CPC, MBS, CBCS, provider educator/chart review for Prevea Health in Green Bay, Wis. "The main difference in the documentation should be lesion versus vessels."

It's in the details: The procedure described in 67228 seals the vessels in the retina so that they no longer leak. Code 67210 represents the procedure ophthalmologists use for lesions that occur on the retina, Zellmer says. "The lesions can be related to diabetic retinopathy, but the documentation should state 'lesion.' I have seen 67228 most often referred to as 'scattered destruction.' "

Tip: When you're scanning the documentation, if the ophthalmologist mentions she entered the posterior chamber, you should choose 67228. "With 67210, the physicians should not be entering the posterior chamber. With 67228, they may enter the posterior chamber," Zellmer says.

Pitfall: You may think that the diagnosis the ophthalmologist dictates will lead you to the proper procedure code. The ophthalmologist can use 67228 to treat both background (362.01) and proliferative diabetic retinopathy (362.02), but he wouldn't use 67210 to treat either of these conditions, Zellmer says. Your physician may use either procedure to treat retinal edema (362.83) and use 67228 to treat retinal ischemia (362.84). Therefore, you shouldn't use the diagnosis "as the determining factor to decide which code is appropriate," Zellmer adds.

The Correct Coding Initiative (CCI) edits bundle 67210 and 67228, indicating that they are mutually exclusive.

When CCI bundles codes and considers them mutually exclusive, you can't report both codes when the same physician performs the procedures on the same day. But a mutually exclusive bundle doesn't mean 67210 and 67228 are never separately billable when performed for the same patient. This bundle carries a modifier indicator of 1, however, meaning CMS allows a modifier to override the edit if circumstances warrant it. Therefore, there are times when you can report both 67210 and 67228.

Example: If your ophthalmologist performs the procedures on two different eyes, you can separately report 67210 and 67228. If a patient presents with retinal edema in his left eye and proliferative diabetic retinopathy in his right eye, you can code 67210-LT (Left side) and 67228-RT (Right side), based on the ophthalmologist's documentation of the procedures. You should also append modifier 59 (Distinct procedural service) to 67210 to indicate that the procedures warrant separate billing.

Best bet: "Make sure that the initial claim does state that the documentation is available for review," Zellmer says. "I, however, would very carefully review the documentation before deciding to append 59. It should be a completely different area of the same eye, or the opposite eye."

Alternative: "Usually we will see 67210 performed first for some type of edema and followed by 67228 for diabetic retinopathy," Evans says. If your ophthalmologist performs 67228 during the global period of 67210 you should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to 67228 to indicate a staged procedure, she adds. Keep in mind that modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) is not appropriate in this scenario.