Ophthalmology and Optometry Coding Alert

Its too soon to say how carriers will respond to modifier -60 (altered surgical field). But CPT 2001 makes it clear that the modifier should not be used with certain codes. If the CPT code descriptor includes the altered field, such as scarring from a previous surgery, the physician work inherent in the scarring is included in the code itself, and therefore the addition of modifier -60 would not be appropriate. Modifier -60 can be used for any re-operation, except for when the procedure is coded differently anyway, explains Michael X. Repka, MD, the American Academy of Ophthalmologys (AAO) representative to the CPT Advisory Committee.

Physicians wanted modifier -60 to get an extra percentage into the fee for complicated surgeries, Repka says. HCFA didnt want this modifier, he notes. In many instances, modifier -60 will replace modifier -22 (unusual procedural services). Because HCFA thought modifier -22 was overused, they agreed to create modifier -60.

Ophthalmologists should use modifier -60 for procedures that involve more complexity and/or time in an altered surgical field. The alteration must result from:

previous surgery;
scarring;
adhesions;
inflammation;
distorted anatomy;
irradiation;
infection;
very low birth weight (i.e., neonates and small infants less than 10 kg); or
trauma.

Use modifier -22 for operative complexity caused by circumstances other than those previously listed.

Modifier -60 can be appended to codes if the requirements (listed above) for the modifier are fulfilled. But many codes are in a gray area sometimes they can be used with modifier -60, and sometimes they cannot.

Exactly how modifier -60 will play out in terms of local Medicare carriers and other payers is unclear at this point. We dont know that the carriers will have a limited list of surgical codes, notes Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based ophthalmology coding and compliance consulting firm. But Duran agrees that proper coding requires that attention be paid to the descriptors of the procedure before using modifier -60. Keep in mind that there are codes already existing in CPT that have an inherent value for the extra work involved, Duran advises.

At this time, there is not a set percentage of increased payment that is going to be attached to the use of modifier -60, Duran says. As with modifier -22, which -60 will replace in many instances, carriers will have to review the operative report for the service in order to determine payment. It takes extra time to submit a paper claim and pull the op note. Make sure the circumstances justify the use of modifier -60.

The three codes in ophthalmology that modifier -60 will probably never apply to because they already have the extra work built into them are:

66172 fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents)

66982 extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, endocapsular rings, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage)

This is a new code for 2001.

+67332 strabismus surgery on patient with scarring of extraocular muscles (e.g., prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (e.g., dysthyroid ophthalmopathy) (list separately in addition to code for primary procedure). Use in conjunction with codes 67311-67318.

Some codes include information in their descriptions that may or may not make it possible to use modifier -60. For example, if a code refers to severing adhesions, you do not use modifier -60 based on the adhesions. If another circumstance applied to the case, such as trauma, which makes the operation more complex, use modifier -60. Look in the descriptors of the following codes to determine if you can append modifier -60:

65860 severing adhesions of anterior segment, laser technique (separate procedure])

65865 severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae

65870 severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure);anterior synechiae, except goniosynechiae

65875 severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); posterior synechiae

65880 severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); corneovitreal adhesions

+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). Use in conjunction with 67311-67318

67343 (release of extensive scar tissue without detaching extraocular muscle [separate procedure])

Note: Due to a typographical error on the inside front cover of CPT 2001, modifier -60 is not listed. It is, however, listed and defined (as are all modifiers) in Appendix A of the manual, beginning on page 357.