Ophthalmology and Optometry Coding Alert

To ensure optimal reimbursement when a trabeculectomy is performed following a trabeculoplasty, you must use the appropriate modifier.

The trabeculoplasty is done by laser, and can be done in the office. It may require more than one session; 65855 covers one or more sessions done within the global period of the first session.

There is now a 90-day post-op period for 65855; this is 90 days from the first session. Sometimes, the trabeculoplastyalso known as ALT, for argon laser trabeculoplastydoesnt work, and the pressure builds again within the 90-day global period of the first trabeculoplasty session, requiring a trabeculectomy (66170, 66172). The trabeculectomy is done in the operating room and is a more extensive procedure. How can you code these two procedures for optimal reimbursement?

Correct Modifier -58 Usage

In general in the Medicare program, when one procedure fails because it didnt fix the problem, you would perform the subsequent procedure using
modifier -58 (staged or related procedure or service by the same physician during the postoperative period), explains Raequell Duran, COA, president of Practice Solutions, an ophthalmology coding and reimbursement consulting company based in Bakersfield, CA. The trabeculectomy following the trabeculoplasty would be a greater procedure following a lesser procedure, says Duran.

Modifier-58 is to be used if any one of the following three conditions are met:

1. the subsequent procedure was staged, or planned at the time of the original procedure;

2. the subsequent procedure was more extensive than
the original procedure (the case of the
trabeculectomy following the trabeculoplasty); or

3. the subsequent procedure was for therapy following
a diagnostic surgical procedure.

Modifier -58 is a cherished modifier because it involves no payment reduction.

Note: If a patient is returned to the operating room for a complication, modifier -78 (return to the operating room for a related procedure during the postoperative period) applies. However, this is not a complication; it is a failed procedure.

Modifier -79: Alternate Code

Another option is to use modifier -79if your carrier does not handle modifier -58 correctly. This is what Jerry Groesch, billing clerk for South Hills Eye Associates in Pittsburgh, PA, uses. Modifier -79 is for an unrelated procedure during the post-op period, and Groesch explains why, even if the diagnosis is the same (glaucoma), the procedures are unrelated.

If the laser is done first, thats just stretching the tissue, she says. A trabeculectomy actually removes the tissue. These are two separate and unrelated procedures. Modifier -79 has no fee reduction.

ALT Before Trabeculectomy?

Sometimes, the reverse order of procedures may occur, says Roxanne Oyler, CPC, business supervisor for Kentucky Eye Care in Louisville, KY. The doctor may want to do the more extensive procedure (trabeculectomy) first, she says, adding that the patients condition may demand that. But the trabeculectomy still may not control the pressure, and he or she may need to do a trabeculoplasty. In this case, you should use modifier -58. Again, the first procedure has failed to achieve the desired results, so more intervention is needed.

Note: This would be a relatively rare occurrence; usually, physicians try the non-invasive procedures before the more invasive ones.

Modifier -78 After Cataract Surgery

Obviously, this is a controversial area. Modifiers -58, -78 and -79 are all possibilities for subsequent trabeculectomy surgery depending on the circumstances. But Lise Roberts, vice president of Health Care Compliance Strategies, a compliance and reimbursement consulting firm based in Syosset, NY, notes that there is one situation in which a trabeculectomyor a trabeculoplastymight be done during the post-op period of another surgery that would clearly call for modifier -78. If you do cataract surgery that then causes the uncommon complication of an increase in the pressure, and you then had to do a trabeculectomy or trabeculoplasty during the post-op period of the cataract surgery, that would be modifier -78.