Ophthalmology and Optometry Coding Alert

Question: An ophthalmologist removes a 6.5-mm section of the lateral rectus muscle of the patient's left eye and resects the muscle to strengthen it and correct strabismus. He then repeats the procedure on the right eye, again removing 6.5 mm of the lateral rectus muscle and then resecting it. Should I use 67311 or 67312?

North Carolina Subscriber

Answer: Because the ophthalmologist resected muscles in different eyes rather than in the same eye, you should report 67311 (Strabismus surgery, recession or resection procedure; 1 horizontal muscle) bilaterally. Code 67312 (Strabismus surgery, recession or resection procedure; 2 horizontal muscles) describes a resection procedure on two horizontal muscles in the same eye and does not describe the procedure in your scenario.

Most Medicare carriers want you to report a bilateral session using one line with modifier 50 (Bilateral procedure) and a "1" in the units field (67311-50).