Ophthalmology and Optometry Coding Alert

CMS ends 150 percent adjustment for 6 strabismus add-on codes

When your ophthalmologist uses adjustable sutures in both eyes during a strabismus operation, you can code the strabismus surgery itself bilaterally. But thanks to a new CMS ruling, you can now only code the stitches once, whether the ophthalmologist used them bilaterally or not.

In May, you learned the good news: Medicare made it possible for you to code several eyelid surgeries bilaterally and earn 150 percent of the single code amount. Now, the other shoe has dropped: Medicare is now preventing you from reporting seven ophthalmic add-on codes bilaterally.

Code These Add-Ons Only Once

Last spring, two CMS transmittals changed the bilateral status of dozens of eye procedures, resulting in most of the eye surgery codes having bilateral status "1" (see "News You Can Use: Earn 150 Percent of RVUs for Most Eyelid Surgery" in the June 2005 Ophthalmology Coding Alert). This status allowed ophthalmology coders to report these procedures bilaterally, with Medicare carriers applying a 150 percent adjustment to the fee for one procedure, says Brenda Parker, CPC, coder for River Cities Ophthalmology in Fort Madison, Iowa.
 
However, CMS Transmittal 672 (Change Request 4031), dated Sep. 9, changes the bilateral status of seven ophthalmic CPT codes from "1" to "0," meaning that  the payment adjustment for bilateral procedures no longer applies.

Once the bilateral indicator changes to "0" for these codes, you'll be unable to use either the LT/RT (Left side/Right side) or 50 (Bilateral procedure) modifiers with them:

• +66990--Use of ophthalmic endoscope (list separately in addition to code for primary procedure)

• +67320--Transposition procedure (e.g., for paretic extraocular muscle), any extraocular muscle (specify) (list separately in addition to code for primary procedure)

• +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)

• +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)
 • + 67334 ...quot; Strabismus surgery by posterior fixation  suture technique, with or without muscle recession (list separately in addition to code for primary procedure)

• +67335--Placement of adjustable suture(s) during  strabismus surgery, including postoperative adjustment(s) of suture(s) (list separately in addition   to code for specific strabismus surgery)

• +67340--Strabismus surgery involving exploration  and/or repair of detached extraocular muscle(s) (list separately in addition to code for primary procedure).

CMS will implement these changes on Oct. 3, 2005. The changes will appear in the October 2005 update to the Medicare Physician Fee Schedule; however, a note in the transmittal says that the above changes are "effective for services performed on or after May 19, 2005."

Report 67320-67340 Alongside Primary Codes

Don't miss: All of the eight affected ophthalmic CPT codes are add-on codes, meaning you cannot report them alone, or as a primary procedure, says Dorothy Smith, CPC, patient accounts manager in the Department of Ophthalmology and Visual Sciences at the University of Maryland School of Medicine.

You must report them in conjunction with another CPT code--specifically, as a note in the CPT manual directs, you must report 67320-67334 in conjunction with 67311-67316 (Strabismus surgery, recession or resection procedure; [horizontal or vertical muscles]) or 67318 (Strabismus surgery, any procedure, superior oblique muscle).
 
You can report 67335 and 67340 with 67320-67334 as well as with 67311-67318, but 67320-67334 are themselves add-on codes that you cannot report without 67311-67318. "Add-on codes (67320-67340) are not considered primary CPT codes and are not separately reportable," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. "They can only be billed and reported with their referenced codes, in this case 67311-67318."

Coding example: The ophthalmologist resects one horizontal muscle in the left eye and one horizontal muscle in the right eye. The patient has scarring on his extraocular muscles from prior strabismus surgery. Code 67311-50 for the strabismus surgery on one line. On the next line, code one unit of 67332--without modifiers--to indicate the patient's scarring. The reimbursement for add-on codes is 100 percent of the fee schedule amount subject to plan deductibles and co-insurance, Mac says.

Note: To read the transmittal, go online to www.cms.hhs.gov/manuals/pm_trans/R672CP.pdf.