Ophthalmology and Optometry Coding Alert

 If an initial retinal repair necessitates a second procedure, look to 78

When you have trouble choosing between modifiers 78 and 79 for a repeat repair of a retinal detachment, ask yourself this question: "Would the patient have required the second surgery if the first surgery hadn't occurred?"
 
If the answer is "no," you should turn to modifier 78 (Return to the operating room for a related procedure during the postoperative period).

Meet 4 Guidelines for 78

You should append modifier 78 when you meet all four of these criteria:
 
1. The surgeon undertook the subsequent surgery because of complications from an initial surgery.
 
2. The subsequent surgery occurred during the global period of the initial surgery.
 
3. The subsequent surgery required a return to the operating room (OR) setting.
 
4. The subsequent surgery was not a greater procedure than the original surgery.
 
Note: A laser suite counts as an OR setting. The Medicare Carriers Manual defines an OR as "a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an OR)."
 
Tip: You should think of 78 as the "complications" modifier, says Susan Allen, CPC, CCS-P, coding manager and compliance officer for a practice in Clearwater, Fla.
 
Example: After cataract surgery, a patient notices floaters. The ophthalmologist performs a pars plana vitrectomy to remove some remaining cataract fragments.
Since the cataract fragments are a complication of the original cataract surgery, you may report 67036-78 (Vitrectomy, mechanical, pars plana approach), if the vitrectomy occurs within the global period for the cataract surgery.

Bundle Procedures That Don't Require OR Visit

If you're billing Medicare carriers, you cannot charge separately for complications that the ophthalmic surgeon handles in an outpatient setting. These could include infection, bleeding or perforation, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.
 
Such services are covered under the surgery's global period, according to Medicare guidelines.
 
Example: An ophthalmologist removes a foreign body from a patient's eyelid (67938, Removal of embedded foreign body, eyelid). Within the 10-day global period, the eye develops an infection. The ophthalmologist cleans, irrigates and treats the site of the infection in the office. That treatment is included in the original procedure and is not separately reportable.

Apply 79 for Brand-New Circumstances

You should apply modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) when you meet three criteria:
 
1. The ophthalmic surgeon must undertake the subsequent surgery for conditions unrelated to the initial surgery.
 
2. The ophthalmologist provides treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery.
 
3. The subsequent surgery occurs during the global period of the initial surgery. 

In other words, Jandroep says, if the same surgeon must perform a separate evaluation and a distinct, unrelated surgery - including all follow-up - for an unrelated medical condition during the global period of a previous procedure, you should append modifier 79 to the subsequent procedure code(s).
 
Example: The ophthalmologist performs cataract extraction with insertion of an intraocular lens (66984, Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique). Following the procedure, the patient develops a retinal detachment that requires a repair (67105, Repair of retinal detachment, one or more sessions; photocoagulation, with or without drainage of subretinal fluid).
 
A physician in the group practice is a retinal specialist, and the patient is referred for evaluation of the detachment and for the repair.
 
The subspecialist codes for a consultation service, 99241-99245 (Office consultation for a new or established patient ...), with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended to show that the consultation is unrelated to the cataract extraction.
 
For the surgical procedure, he codes 67105-79, plus the LT (Left side) or RT (Right side) modifier, says Wanda Williams, coder for Alexandria Eye and Laser Center in Alexandria, La.
 
Although the patient did not have a detachment prior to the first surgery, Medicare does not consider the condition to be related to the cataract surgery because it is not a normal course of treatment following cataract surgery.
 
Not every patient who undergoes cataract surgery develops a retinal detachment, so the two conditions are not related in Medicare's eyes.