Ophthalmology and Optometry Coding Alert

Question: A patient with commercial insurance underwent a YAG capsulotomy on the left eye the same day as cataract surgery was performed on the right eye. This was done as a convenience for the patient because she didn't want to undergo two separate operative sessions. We reported 66982 for the cataract surgery and 66821-79 for the YAG service but got a denial. What did we do wrong?

Codify Subscriber

Answer: Most likely, the problem lies with the modifier you appended to the claim. Although modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) may sound appropriate for this situation, it is not the right modifier for the scenario. Modifier 79 applies when you see a patient for an unrelated service during the global period of another procedure, not for two services performed concurrently.

Since multiple procedures were performed on the same day and during the same surgical session, your first instinct should be to check for any bundled codes according to Correct Coding Initiative (CCI) edits. You'll note that 66821 (Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery [eg, YAG laser] [1 or more stages]) is bundled into 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [1-stage procedure], manual or mechanical technique [eg, irrigation and aspiration or phacoemulsification], complex, requiring devices or techniques not generally used in routine cataract surgery [eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis] or performed on patients in the amblyogenic developmental stage).

The CCI bundle has an indicator of 1, which means they can be unbundled in certain circumstances using a modifier such as 59 (Distinct procedural service) or the LT (Left side) and RT (Right side) modifiers.

When is it appropriate to separate bundled codes? When you want to identify that the procedures were "distinct" from other services performed on the same day, and thus receive payment for both. Typically, "distinct" means performed on a different site or organ system, in a different session, different incision, etc. In this scenario, you should have used modifier 59 or the LT/RT modifiers, depending on your payer's preference, rather than modifier 79. In addition, many payers are accepting the "X" modifiers (such as XU, XS, XP, and XE) in place of the modifier 59 because they are more descriptive.

Note: Just because you unbundle two codes doesn't mean you'll get fully reimbursed for each. A multiple procedure discount may still apply, depending on your payer's rules.