Ophthalmology and Optometry Coding Alert

Make sure your documentation justifies separate services

If you regularly code intravitreal injections along with retinal repairs, brace yourself: The latest round of National Correct Coding Initiative (NCCI) edits, which became effective on Jan. 1, makes it clear that Medicare doesn't want to see them reported separately.

NCCI version 12.0 adds a startling 59,080 new nonmutually exclusive edits and 465 new mutually exclusive edits. It deletes only 60 nonmutually exclusive edits.

One new edit makes 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) a component of 67107 (Repair of retinal detachment; scleral buckling [such as lamellar scleral dissection, imbrication or encircling procedure], with or without implant, with or without cryotherapy, photocoagulation and drainage of subretinal fluid) and 67115 (Release of encircling material [posterior segment]).

Previous edits have bundled 67028 into all of the other retinal repair codes (67101-67121). With these new edits, NCCI affirms that injection of pharmacologic agents (such as antibiotics or a steroid such as Kenalog) is an intrinsic part of retinal repair and cannot be reported separately unless the injection represents a truly distinct service.

Coders often turn to 67028 to report therapeutic injections of Kenalog or Macugen, says Bonnie Kellay, COT, director of clinic operations at Grand Rapids Ophthalmology in Grand Rapids, Mich. Reporting 67028 as a separate procedure is appropriate in these situations.

Break Infusion Bundles With Modifiers When Necessary

The hardest hit codes in the new NCCI are the drug administration codes that took effect in January. Hydration code 90760 and initial infusion code 90765 each become components of 5,737 other codes, including 256 codes in the "Eye and Ocular Adnexa" section of CPT.

Injection code 90772 and IV push codes 90774 and 90775 each become a component of nearly as many codes, more than 5,700 each (255 eye surgery codes).

Override opportunity: You'll be able to use a modifier to override some of these edits, but not all of them.

Example: NCCI 12.0 bundles 90772, 90774 and 90775 into 67221 (Destruction of localized lesion of choroid; photodynamic therapy [includes intravenous infusion]). Those bundles carry modifier indicator "1," which means you can report a therapeutic injection or IV push along with 67221, appending the appropriate modifier to the 9077x code, if both procedures were medically necessary.

However, NCCI 12.0 also bundles intravenous infusion codes 90760 and 90765 into 67221. Those bundles carry modifier indicator "0," which prevents you from ever reporting those services separately.

Some of these edits applied to last year's G codes, and CMS is just carrying them over to the new CPT codes, experts say. Eighty-four E/M codes also become components of 90760, 90765, 90772 and 90774. You can use a modifier to override all of those edits except the ones governing a level-one office visit (99211).

Do this: Download the complete set of NCCI edits from the CMS Web site at www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp.