Ophthalmology and Optometry Coding Alert

When an ophthalmologist begins a surgical procedure but can't complete it, coders should know when to append modifier -53, -22 or -78 for fair and optimal reimbursement.

Modifier -53: Determine How Much of the Procedure Was Completed
 
Modifier -53 (discontinued procedure) for discontinued surgery tells the payer that the physician did not complete the procedure. Although the ophthalmologist's fee will be reduced accordingly, there is no prescribed reduction amount. The physician needs to determine how much of the procedure he or she completed, as well as how much follow-up will be necessary, and bill accordingly. 

For example, a patient is prepped and draped for phacofragmentation cataract surgery with IOL insertion. The anesthesiologist starts monitored anesthesia care (sedation). The surgeon performs a retrobulbar block. The surgeon makes the incision and starts removing the cataract, but the patient starts moving on the table. At this point the anesthesiologist usually delivers more medication intravenously, but it may not be effective. "The surgeon determines that he or she needs to stop and close up," says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. 

"The surgeon will usually opt for general anesthesia during the next try," Roberts says. This surgery would be coded 66850 (removal of lens material; phacofragmentation technique [mechanical or ultrasonic] [e.g., phacoemulsification], with aspiration) with modifier -53 appended.

For a minor procedure, consider the patient who cannot tolerate punctal plugs. The patient has excessively dry eyes, and the doctor plans to place punctal plugs in the lower puncta initially. But when the patient starts yelping -- even if the doctor is using a local anesthetic -- and is unable to sit still, the doctor has to stop.

"A lot of ophthalmologists might say, 'Let's just bill for an office visit,'" Roberts says. "But you should bill this as a discontinued punctal-plug insertion because of the supply." Medicare and other payers cover permanent plugs, but not temporary plugs, as a supply. In this case, the plugs would probably be collagen. The sterile package usually contains two plugs and would cost the practice at least $60 even though the physician couldn't insert them.

Bill for the procedure with 68761 (closure of the lacrimal punctum; by plug), with the appropriate eyelid modifier and modifier -53 appended. For example, if you attempt to place a plug in the upper left eyelid, bill 68761-53-E1. Always use modifier -53 before the eyelid modifier because payment modifiers always go in the primary position following the code, with the information modifier in the secondary position. 

Sometimes a patient needs more than one plug. Perhaps you were able to implant one plug, but when you got to the second, you had to stop. For instance, you successfully placed a plug in the lower right lid, but when you got to the upper right, the patient became uncooperative and you decided to discontinue that procedure. Code 68761-E4 for the lower right lid, and 68761-53-E3 for the upper right lid.

If permanent silicone-type plugs are used, you should bill for the supply using A4263 (permanent, long-term, nondissolvable lacrimal duct implant, each). This is a sterile supply, so you should bill even if the procedure was not completed.  

When an ophthalmologist has to discontinue a procedure, he or she may discuss other alternatives with the patient. There are other methods of closing the puncta -- such as suturing or laser closure. If the ophthalmologist spends more than 50 percent of the encounter time on such counseling, bill an E/M service with the level based on time. 
 
Use Modifier -22 for Extra Work
 
In another example, a patient needs a retinal procedure. The patient had a bad bout of proliferative diabetic retinopathy (250.5) and had two prior surgeries with epiretinal membrane stripping. Now the patient has a membrane again and a macular pucker. The physician must perform a vitrectomy with membrane peeling (67038, vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping). Although the patient has little or no vitreous left after the two previous procedures, this is still the correct code, Roberts says.

The epiretinal membrane stripping is very difficult. "This a typical tough case," Roberts says. The surgeon attempts to remove the membrane to reduce or eliminate the macular pucker, but finds that the membrane is tenuous and adherent to the retina. The physician cannot complete the procedure because he or she can't completely remove the membrane, and the pucker in the macular membrane is not improved. The surgeon may decide to stop the case and close.

The postoperative care would be the same as if the procedure had been completed. In this scenario, the surgeon has often done as much work as or more delicate work than if he or she had been successful in removing the membrane.  

Although the procedure was discontinued, the surgeon should bill the full fee and attach modifier -22 (unusual procedural services) to indicate that this was an unusual case. The correct coding would be 67038-22. 

Do not use modifier -53 in this case because it is a payment modifier that generates a reduced reim-bursement, which would be inappropriate given the extra work performed.
 
Use Modifier -78 for Reoperation
 
If  you have to take the patient back to the operating room for a reattempt within 90 days of the original procedure, you will have to bill the reoperation with a  modifier -78 (return to the operating room for a related procedure during the postoperative period). The initial surgery will still be billed with modifier -53. As in the case above where the ophthalmologist stopped the cataract phacofragmentation because of patient movement on the operating table, when the patient is brought back within 90 days of the discontinued procedure and the case is successfully completed (usually because the patient undergoes general anesthesia instead of local or monitored anesthesia), the procedure will be coded 66984-78-RT (extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification] -right side) or 66984-78-LT (... left side).
 
Billing the Postoperative Care
 
The physician's plan for follow-up is important to billing, since the procedure code includes postoperative care, Roberts explains. "There is a presumption that post-op care will be included, even if you use modifier -53," she says. Discontinuing a procedure might reflect the need for extra postoperative care. If you don't consider the amount of postoperative care you will have to provide after discontinuing a procedure, you may be missing out on payments.

Often, physicians assume that because they performed 50 percent of, for example, a  $1,000 procedure, they can bill $500. But because the ophthalmologist may end up providing more post-op care for a discontinued procedure than he or she would for a completed procedure, you should take that into account. Here's how:

The postoperative portion of any global surgical package is 20 percent. For the $1,000 procedure, $100 is for the preoperative visit (10 percent), $700 is for the procedure itself, and $200 is for the postop care. If the physician performs only half of the full procedure, bill all of the preoperative portion and half of the intraoperative, and, depending on how much postoperative care is anticipated, you may need to bill for all of the postoperative care. The appropriate charge in this case could be $650 instead of $500.

Note: See box at right for how to bill incomplete procedures in an ASC.