Ophthalmology and Optometry Coding Alert

Question: The physician performed pterygium excision and we reported 65426 (Excision or transposition of pterygium; with graft). The documentation to support the claim was as follows:

The patient was prepped in a sterile fashion and anesthetized. The pterygium was separated from the underlying scar tissue of the sclera, and a muscle hook was passed through the upper conjunctiva. The head of the pterygium was dissected carefully from the apex toward the limbus, the upper angle of the conjunctiva was grasped with fine forceps. Westcott scissors were employed to separate the conjunctiva from the underlying Tenon's capsule. Bleeding was controlled using electrocautery and TobraDex was placed in the eye. The eye was patched and the patient was asked to report back to our office the next day for evaluation.

We were paid for the claim, but upon review, the claim was downgraded to 65420 (Excision or transposition of pterygium; without graft) and the payer wants money back. Should we appeal?

Codify Subscriber

Answer: No, in this situation, the insurer is correct. Although your operative note is very detailed and thorough, it does not mention placement of a graft. Therefore, this claim was incorrectly billed and the documentation was insufficient to support CPT^® code 65426. The contractor would therefore change this to CPT^® code 65420, and you will need to return the overage.

Since 65420 pays about $530 in the facility setting and 65426 reimburses approximately $670, you're likely to have to repay about $140 for the error.