Ophthalmology and Optometry Coding Alert

Get the answers — straight from experts at the AAO conference.

Coding an ophthalmology chart can sometimes involve reading a simple op report that you can code off the top of your head, while other times you’ll have to perform hours of research before selecting the accurate code. If your cases typically fall somewhere in between these extremes, you might benefit from a quick tutorial on how to code a quick operative note.

Consider the following two cases and expert answers presented during the American Academy of Ophthalmology’s October conference to determine the best way to code these ophthalmology claims.

Know the Exam Rules

Code This #1: This case and solution were presented at AAO by Carrie A. Lembach, DO and Jenny Edgar, CPC, CPCO, OCS: An established Part B patient says that she is experiencing pain of the left eye and increased tearing, which has lasted for three years, but has worsened in the last week. The patient has a history of aphakic bullous keratopathy, but is not interested in surgery. The physician performs a review of systems of the eyes, and reviews past, medical and social history.

The doctor performs an expanded problem-focused exam, with the medical decision-making portion of the note stating, “Recurrent corneal erosion; will apply amniotic membrane transplantation (AMT) today. Risks/benefits reviewed, documented, and patient agrees to proceed.”

Solution 1: Before you start tallying E/M components, check out the CCI edits for the AMT, and you’ll find that an exam is already included in the code allowance. “While medically necessary, if the reason for the established patient exam is performed solely to confirm the need for the minor procedure, it is not separately billable,” Edgar told AAO attendees. Therefore, she says, you cannot report the exam and the AMT placement together, and you should submit only 65778-LT (Placement of amniotic membrane on the ocular surface; without sutures, Left side) for this service.

Keep in Mind the ‘Staged Procedure’ Regs

Code This #2: The following case was coded at AAO by Elizabeth Cottle, CPC, OCS of OHSU-Casey Eye Institute: Patient is still in the postoperative period of her stage one Hughes procedure, but returns to the OR for the second stage.

Solution #2: Because the patient is still in the postoperative period of the stage one procedure (67971, Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, 1 stage or first stage), to get reimbursement for the stage two service, you’ll need to append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to 67975 (Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage), she says.

Here’s why: CMS guidelines stipulate that you should attach modifier 58 when a subsequent procedure in the postoperative period of the first procedure is:

• planned or “staged” or
• more extensive than the original procedure; or 
• for therapy following a diagnostic surgical procedure; or
• for the reapplication of the cast within the 90-day global period.

A common pointer is that you can typically use modifier 58 when the need for the follow-up procedure arises because of the same condition/problem that prompted the initial procedure. Whether planned or not, the second procedure may be construed as the second part of the complete treatment for the diagnosed condition. Although your physician will document each stage of the procedure, including plans for returning the patient to the operating room for additional procedures, he may not exactly spell out the plan in the records.

Hint:  You should automatically think of modifier 58 if the medical record shows that the doctor anticipated a subsequent surgery or procedure.