Question: I have an operative note detailing an ophthalmologist’s strabismus surgical procedure on both eyes of a patient. The note indicates the surgeon resected the lateral rectus muscle of the left eye and resected the medial rectus muscle of the right eye.
Can I report 67312 for this procedure?
Indiana Subscriber
Answer: No, you won’t report 67312 (Strabismus surgery, recession or resection procedure; 2 horizontal muscles) for this procedure because the strabismus surgery codes 67311-67318 (Strabismus surgery …) are inherently unilateral. This means that the codes reflect procedures performed on only one eye. CPT® is implying that if the surgeon operates on two horizontal muscles, those muscles are both on either the right or left eye — not two horizontal eye muscles on the entire patient.
Instead, you’ll assign 67311 (Strabismus surgery, recession or resection procedure; 1 horizontal muscle) as a bilateral procedure. You’ll need to review your individual payer preferences to confirm if the payer uses modifier 50 (Bilateral procedure) or RT (Right side) and LT (Left side) to report unilateral procedures performed on both sides of the body.
Mike Shaughnessy, BA, CPC, Development Editor, AAPC
