Ophthalmology and Optometry Coding Alert

Question: A patient presented with background diabetic retinopathy and retinal edema in her left eye, and the ophthalmologist treated her with photocoagulation. A month later the same patient returned with proliferative diabetic retinopathy and macular puckering, and the ophthalmologist again treated her with photocoagulation. Can we bill both procedures, or is one included in the other because it occurred within the global surgical period?

Maryland Subscriber

Answer: You should be able to bill for both procedures. The CPT^® codes for photocoagulation — 67210 (Treatment of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; photocoagulation) and 67228 (Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation) — seem similar, but they treat very different disorders.

Since the first treatment was for background diabetic retinopathy, report it with 67210 linked to ICD-9 code 362.01 (Background diabetic retinopathy) and 362.83 (Retinal edema). Report the second visit with 67228 linked to 362.02 (Proliferative diabetic retinopathy) and 362.56 (Macular puckering).

Append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 67228 to show that the second treatment was not related to (or made necessary by) the first. Append modifier LT (Left side) to both CPT^® codes to specify which eye was operated on. Remember to always use “payment” modifiers such as 79 before “informational” modifiers like LT (e.g., 67228-79-LT).