Ophthalmology and Optometry Coding Alert

Remember: CPT^® code 67108 isn’t only for initial repairs.

There are thousands of new detached retina cases each year, and as this number grows, it is increasingly important for ophthalmology coders to understand the ins and outs of coding the various retinal detachment treatments. Securing rightful reimbursement hinges on having in-depth knowledge of the procedures and how to handle recurrent and complex repairs.

But you can ensure proper application of these codes by busting these four common myths about retinal detachment repair reporting.

Myth: When Treatment Type Switches, Bill the First Procedure

Reality: When the provider begins one type of detached retina repair but switches to another treatment modality to complete the procedure, only code the repair the provider finished, not the one abandoned.

Example: The ophthalmologist begins treatment of a detached retina with cryotherapy, but due to the patient’s inability to tolerate it, switches to photocoagulation to complete the procedure. In this case, only submit photocoagulation code 67105 (Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation), as that’s the procedure the provider completed. Do not report 67101 (… cryotherapy) for the initial treatment.

However, you may be able to append modifier 22 (Increased procedural services) to 67105 to indicate the additional work performed in converting from one procedure to another. Keep in mind, the additional work must be significant and documented in the procedure note.

Myth: CPT^® 67108 Always Represents Initial Detachment Repair

Reality: This rule of thumb does not always apply, and that’s a good thing. You may report 67108 (Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique) with the appropriate modifier to code a repair of recurrent retinal detachment when the definition of the code is met. As long as the ophthalmic surgeon performs the elements that are described in 67108, you can use that code to bill the service, regardless of whether it’s the initial surgery or a subsequent 67108 service.

Example: A patient undergoes retinal repair with vitrectomy (67108) in their right eye and three weeks later, returns with a retinal detachment in the left eye, for which the provider performs the same procedure. You’ll code the second repair using 67108 with modifier 79 (Unrelated procedure or service by the same physician… during the postoperative period) appended: 67108-79. Make sure the documentation indicates that both retinal detachments were managed using the treatment method outlined by the descriptor for 67108 within the 90-day postoperative period for the first procedure.

Don’t forget to submit 67108 with modifier RT (Right side) for the first surgery on the right eye and -LT (Left side) (with -79 if during the global of the first surgery) for the subsequent surgery on the left eye, advises Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida. “The CPT^® code is considered unilateral, so it should always be submitted with the correct anatomic modifier regardless of when the surgery took place,” she says.

Myth: Always Append -58 for Subsequent Repairs

Reality: Not always. Let’s suppose, for example, a patient undergoes retinal detachment repair, and two weeks later, returns because the retinal detachment recurs in the same location as the first, and subsequent surgery via the same repair method is needed.

Under these circumstances, your instinct might tell you that you can append modifier 58 (Staged or related procedure or service by the same physician … during the postoperative period) to the repair code. However, you can’t use -58 simply because another procedure is being performed to fix the initial problem.

Since the re-repair is related to the original procedure and falls within the global period, you’d report the second surgery using the same repair code with modifier 78 (Unplanned return to the operating/procedure room by the same physician … for a related procedure during the postoperative period) appended, says Karla Philippou, CPC, RHIT, CCS, CCS-P, CHCC, of Cambridge Management Group, a healthcare consulting company based in Tampa, Florida.

Note: You should only append modifier 58 if the subsequent procedure is pre-planned (staged), more extensive than the original surgery, or for therapy following a surgical procedure.

The example above does not meet the first criterion because the physician did not plan for the retina to detach again. The second criterion is not met because the first and second procedures are valued the same, and the third criterion also does not apply to the example. Therefore, you should not append modifier 58 to the CPT^® code for the repeat surgery under these circumstances, Mac says.

Also, you should avoid using modifier 58 with any procedures whose code descriptors indicate “one or more sessions.”

Myth: Rely on 67113 for All Difficult Retinal Detachment Repairs

Reality: Sometimes, but not always. CPT^® code 67113 (Repair of complex retinal detachment … with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy …) is the most extensive retinal repair code. However, you’ll only use 67113 when the ophthalmologist performs a repair with vitrectomy as described in 67108, as well as epiretinal membrane stripping — the peeling away of scar tissue across the macula — which can make this a more complex procedure, according to Mac.