Ophthalmology and Optometry Coding Alert

Its not as easy to code multiple-procedure surgeries as it used to be. There are so many Medicare bundles to watch out for. Camilla Beasley, ART, of the Department of Ophthalmology at the Vanderbilt University Medical Center in Nashville, TN, wants some help coding the following scenario involving two procedures: one is pars-plana vitrectomy with retinal membrane stripping, pan-retinal endolaser, fluid/air exchange, and intravitreal injection of 20-percent sulfur hexafluoride gas. For this one procedure the code is 67038. The second procedure is scleral buckling with explants. This code is 67108 (repair of retinal detachment; 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). The big question is, can you bill 67038 and 67108 together?

For an answer, we talked to Yvonne Wade, insurance administrator for the Center for Sight, a two-ophthalmologist office in Conyers, GA. The first thing you have to do is check your Correct Coding Initiative [CCI] book to see if 67038 and 67108 are bundled, says Wade. When you do that, you can see that both are surgical procedures, so you can bill both codes. But you will need to use the -51 modifier, says Wade, and that means you have to pick either 67038 or 67108 as the primary procedure.

Modifier -51 is for multiple procedures, and CPT defines the modifier this way: When multiple procedures, other than Evaluation and Management Services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier -51 to the additional procedure or service code(s).

Medicare will use the modifier -51 to automatically reduce by half the amount you would normally be paid for doing the procedure to which the modifier is appended, explains Wade. You need to check your fee schedule for Medicare, and see which pays the most, and which pays the least. The procedure which pays the most should be listed as the primary procedure, and the one which pays the least should get the -51 modifier. Theyll pay full on the primary, and half of the one with the modifier, says Wade.

In addition to the -51 modifier, you need to use the modifier indicating which eye the procedure is being done on (LT or RT). The eye modifier is appended to the
51 modifier (e.g., 67108-51-LT).

So, when you are doing a multiple-procedure vitrectomyor any set of multiple proceduresfirst check to see if they are bundled. If not, then determine which one pays the best; make the best-paying the primary, and put the -51 modifier on the other.