Ophthalmology and Optometry Coding Alert

Don’t forget: You should check global days even for minor procedures.

Your optometrists, nurse practitioners, and physician assistants may not perform surgeries, but that doesn’t mean they can ignore global periods.

Here’s why: Not only do minor procedures have some global periods associated with them, but even services that have “000” global days actually still fall under the global surgical package rules. Therefore, your providers who don’t perform surgeries should be just as aware of the global surgical regulations as other clinicians.

Consider these tips to ensure that your entire staff is aware of the global surgical package rules and know how to apply them when applicable.

Understand How Surgical Packages Work

When your clinicians perform a procedure, the payer will include some associated services in your payment for the procedure. That means that in most cases, you won’t be able to separately report any visits related to the surgery separately, unless you encounter specific complications. Although many coders think of surgeries as having 90-day global packages, there are procedures that have shorter global periods than that.

For instance: Suppose you see a patient twice in the same week. During the first visit, the optometrist inserts punctal plugs into the patient’s eyes. On the subsequent visit, the optometrist checks to make sure the patient’s eyes are less dry and that the plugs are staying in place properly. What do you report for the subsequent visit after the plug insertion?

The reality is that if you report a punctal plug insertion code such as 68761 (Closure of the lacrimal punctum; by plug, each), then any E/M code you use for the next 10 days will be bundled into the initial plug placement payment, because these codes have 10-day postoperative periods.

On the other hand, if you perform an E/M service during that 10-day global period for an issue that is unrelated to the punctal plug insertion, bill the office visit with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to indicate it is not included in the global period. Without the use of the 24 modifier, the visit will bundle as being included in the surgical package. Modifier 24 typically applies if you meet these rules:

1. The same provider or a provider in the same group of the same specialty who performs the punctal plug insertion performs the subsequent E/M.
2. The patient reports for treatment of the unrelated issue while still in the global period for the punctal plug insertion.
3. The second E/M is unrelated to the punctal plug insertion.

Don’t Be Surprised by Globals

The number of commonly performed procedures linked to 10-day global periods may surprise you, and include the following, among others:

• 65855 (Trabeculoplasty by laser surgery)
• 66761 (Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session))
• 67800 (Excision of chalazion; single)
• 11440 (Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less)

Therefore, if you perform one of these procedures and you administer an E/M service within the next 10 days that’s related to the procedure, your insurer will likely bundle the payment for the E/M service into the reimbursement you received for the procedure.

If, however, you perform an E/M that’s not related to the procedure, you can use modifier 24 to separate it.

Know the Rules for ‘000’ Day Globals

Some services have “000” global days assigned to them, and although you may think that “000” truly means “zero,” that’s not the case. The 000 classification means the procedure adheres to bundling rules only on the date of the service. Most payers will therefore bundle all services that you perform on the procedure date into codes with the 000 global period.

Commonly performed eye procedures such as the following carry “000” global days:

• 65205 (Removal of foreign body, external eye; conjunctival superficial)
• 65210 (Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating)
• 65222 (Removal of foreign body, external eye; corneal, with slit lamp)

Therefore, if you perform an E/M service that prompts you to perform a foreign body removal (FBR) from the eye, the payer will typically bundle the associated E/M service on that date into the payment for the FBR service.

X’ Marks the Spot for These Procedures

You’ll also notice that some services carry a global period of “XXX.” An XXX modifier means the service is truly free of global surgical bundling issues, meaning that unless National Correct Coding Initiative (NCCI) or payer-specific edits bar you from billing the procedure with an E/M code, you should be free to bill an E/M service with the procedure on the date of service.

Commonly reported eye care procedures with XXX global periods include the following, among others:

• 92201 (Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral)
• 92071 (Fitting of contact lens for treatment of ocular surface disease)

Therefore, if you perform an E/M service that prompts the optometrist to decide they should perform ophthalmoscopy, you should be able to report the E/M code with 92201 without any modifiers appended.