Ophthalmology and Optometry Coding Alert

Question: If an ophthalmologist needs to repair a wound following a trabeculectomy (66170), what is the best way to code for this procedure? Can wound revision (66250) be used instead of Argon laser suture lysis, which the carrier denied?

Shigemi Sugiki, MD
Honolulu, HI

Answer: The trabeculectomy is the removal of part of the trabecular meshworkthe part of the eye that filters fluid and controls its flow before leaving the anterior chamber. It is done to treat glaucoma. The eye produces too much fluid because theres too much pressure, and the fluid doesnt drain out. The filtering blebthe trabeculectomylets the fluid drain out. Sometimes when a surgeon performs trabeculectomy, he places a suture with the intention of cutting it during the postoperative period if the flow is too restricted by the suture.

Suture removal/snipping to affect the flow through the trabeculectomy should not be billed to Medicare because of Medicares definition of whats included in the global surgical package. The Medicare Carriers Manual (MCM) states that the global surgical package includes miscellaneous servicesitems such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints ...

For ophthalmology, items such as would include suture removal by any method, Jones tube removal and punctal plug removal.

Some practices address this situation by billing for the same procedure (66170) again. The second time, they use the -78 modifier (return to operating room for a related procedure during the postoperative period), and Medicare pays for the procedure at 50 percent. But this is not correct coding. Neither is using the revision or repair of operative wound code (66250).

The bottom line: Lysing sutures early or late by laser or any other method is considered part of the global surgical package.

Note: Unfortunately, there are Medicare carriers paying for the use of 66250. This complicates getting people to do correct billing. Just because the carrier pays doesnt mean it was billed correctly. In an audit, people billing these could find themselves in a tough position and face fines. If a local carrier has published a Limited Medical Review Policy (LMRP) that allows billing 66250 with trabeculectomy, that would be the only way it could be considered appropriate billing in that carriers jurisdiction.

Sources for answers: Lise Roberts, vice president, Health Care Compliance Strategies, Syosset, NY; Marie Stamper, CMM, Office Manager, Ward Eye Center, Homosassa, FL.