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Ophthalmology and Optometry Coding Alert

Master These Complicated Strabismus Coding Cases to Avoid Costly Denials

Published on Wed Nov 17, 2004

Billing bilaterally can save you $130 per procedure

A simple mistake coding the many combinations of strabismus surgery could cost your practice hundreds - unless you know the ropes.

Make Modifier -50 Your Secret Weapon

Scenario: An ophthalmologist removes a 6.5-mm section of the lateral rectus muscle of the patient's left eye and resects the muscle to strengthen it and correct strabismus. He then repeats the procedure on the right eye again removing 6.5 mm of the lateral rectus muscle and then resecting it. Two different codes might look correct - but only one will bring you the reimbursement you deserve.

Because the ophthalmologist performed a resection procedure on two horizontal muscles CPT code 67312 (Strabismus surgery recession or resection procedure; two horizontal muscles) may look correct but don't fall into this trap.

The strabismus surgery codes (67311-67318) describe procedures done in one eye only says Christina Martell CPC billing manager for Pediatric Ophthalmic Consultants in New York City. Even though the surgeon did resect two muscles they were in different eyes so 67312 is not correct Martell says.

Instead you should report 67311 (Strabismus surgery recession or resection procedure; one horizontal muscle) bilaterally Martell says. Most Medicare carriers want you to report the entire session on one line with modifier -50 (Bilateral procedure) and a ""1"" in the units field.

Warning: Reporting 67312 would even hurt your reimbursement in this case. In the Medicare Physician Fee Schedule Database 67311 has a bilateral modifier indicator of ""1."" This means that if you report 67311-50 or report two instances of 67311 on two lines - for example 67311-LT for the left eye and 67311-RT-51 (Multiple procedures) for the right - Medicare will base payment on 150 percent of fee schedule amount for a single code.

Medicare multiplies the facility RVUs for code 67311 (13.39) by the conversion factor of 37.3374 arriving at $499.95. Appending modifier -50 for the bilateral procedure means that Medicare would reimburse you 150 percent of that giving you $749.92.

Reporting 67312 however even though the descriptor mentions ""two horizontal muscles "" will short-change you. With no bilateral pay adjustment the RVUs for 67312 would only bring in $616.08.

Select a Single Code for Single-Eye Muscles

To code strabismus surgery correctly you also need to know when it is not appropriate to report strabismus surgery bilaterally.

If the ophthalmologist recesses both the lateral rectus and medial rectus muscles of the left eye that is not a bilateral procedure. This is a case in which 67312 would be appropriate says Mary Schwall CPC clinical practice specialist at the Yale Eye Center in New Haven Conn.

The same rules apply for the vertical muscles (the superior rectus inferior rectus and inferior oblique muscles).

Use these CPT codes for the following strabismus scenarios based on which muscles were worked on:

  •   67311 for one horizontal muscle in one eye

  •   67312 for two horizontal muscles in one eye

  •   67314 for one vertical muscle in one eye

  •   67316 for two or more vertical muscles in one eye

  •   67318 for the superior oblique muscle in one eye

    If the ophthalmologist operates on one vertical and one horizontal muscle in one eye however use two codes - 67311 and 67314 (... one vertical muscle [excluding superior oblique]).

    Practice: So how would you code if your ophthalmologist operates on both horizontal muscles in the left eye but only one horizontal muscle in the right eye? Use 67312-LT (for the two muscles in the left eye) and 67311-51-RT (for the single muscle in the right eye) Schwall says. Reporting 67311 bilaterally for the horizontal muscles in both eyes would not be appropriate.

    Save Add-On Code for Special Occasions

    You should use add-on codes whenever the operative report clearly documents an additional procedure - an adjustable suture for instance - or a complicating condition or history.

    A careful coder may be aware of a condition in the patient history that is not stated in the operative report. This fact should be called to the attention of the surgeon so that he can edit it in the operative report to allow billing.

    Requirement: All add-on procedures and services those CPT codes proceeded by a ""+ "" must be reported with another code representing the primary procedure.

    For example +67320 (Transposition procedure [e.g. for paretic extraocular muscle] any extraocular muscle [specify] [list separately in addition to code for primary procedure]) is for use in conjunction with strabismus surgery codes 67311-67318 according to CPT guidelines.

    Codes +67331 (Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles [list separately in addition to code for primary procedure]) +67332 (Strabismus surgery on patient with scarring of extraocular muscles or restrictive myopathy [list separately in addition to code for primary procedure]) and +67334 (Strabismus surgery by posterior fixation suture technique with or without muscle recession [list separately in addition to code for primary procedure]) likewise can only be reported with  codes 67311-67318.

    Don't overlook: You can report +67335 (Placement of adjustable suture[s] during strabismus surgery including postoperative adjustment[s] of suture[s] [list separately ...]) and +67340 (Strabismus surgery involving exploration and/or repair of detached extraocular muscle[s] [list separately ...]) not only with strabismus-surgery codes 67311-67318 but also with  add-on codes 67320-67334.

    But 67320-67334 must themselves be reported with a primary procedure code. Many trauma cases may involve multiple add-on codes Schwall says - for instance in the case of an open globe in which the ophthalmologist would have to explore for damaged muscles and insert an adjustable suture.

    Red flag: Add-on codes have an inherent reduction in value because it is clear they are billed in addition to a primary procedure. Never append modifier -51 (Multiple procedures) to add-on codes or the already reduced add-on code fee could be reduced by an additional 50 percent.

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