Ophthalmology and Optometry Coding Alert

Question: If the ophthalmologist performs 67210-RT and a month later the patient returns and the ophthalmologist performs 67228-RT for leakage, can we get paid for the second procedure even though it was performed during the postoperative period of 67210 and it is bundled into 67210 by the NCCI edits?

Virginia Subscriber

Answer: There are a lot of factors at work here global periods, NCCI edits, even modifiers but the determining factor is whether you have the documentation of medical necessity for 67228.

When two codes are bundled together, as 67210 (Destruction 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 [laser or xenon arc]) are by the National Correct Coding Initiative (NCCI) edits, it's not always clear whether the two codes can ever be billed for the same patient regarding the same problem. To clarify, codes bundled by the NCCI edits are not to be billed on the same day of surgery. But if the bundled procedures are rendered on separate days, the bundle does not always apply.

Even though the NCCI bundle no longer applies in your case, you will still need to consider that 67228 was performed in the postoperative period of 67210, which means you need to append a modifier to the second code to receive reimbursement and for the second procedure to be considered not included in the global surgical package of 67210.

If there are no findings to indicate that the leakage is a complication of the first laser treatment and there is documented medical necessity for the second laser procedure, you need to append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to the second laser procedure.

Answers to You Be the Coder and Reader Questions provided by Raequell Duran, president, Practice Solutions, Santa Barbara, Calif.