Ophthalmology and Optometry Coding Alert

Question: Our doctors are retina specialists. One of the physicians performed a pneumatic retinal detachment repair (67110) and cryotherapy (67141) on the same date. They are different procedures and we did apply a modifier to 67141 to show that they are distinctly different, but we are still getting denials. Can you advise?

Indiana Subscriber

Answer: Although the Correct Coding Initiative (CCI) does bundle 67141 (Prophylaxis of retinal detachment [eg, retinal break, lattice degeneration] without drainage, 1 or more sessions; cryotherapy, diathermy) into 67110 (Repair of retinal detachment; by injection of air or other gas [eg, pneumatic retinopexy]), the CCI manual clearly states that you can use a modifier to report the codes together if you meet the criteria to properly separate the two services. This is done with modifier 59 (Distinct procedural service) and documentation must support one of the following:

• Different encounter or session
• Different surgery or procedure
• Different organ system or body site
• Separate lesion
• Separate injury

If you don’t meet the above criteria for billing the additional procedure and documentation does not support the appendage of modifier 59, you should not be paid per the CCI Edits that CMS follows for payment purposes.

If you have met the above criteria and you’re still seeing denials, it’s possible that you aren’t using an appropriate modifier to separate the services. For instance, not all payers accept the eye modifiers (E1-E4) and some may even reject the claim if it includes LT (Left side) and RT (Right side) instead of a modifier like 59.

However, it’s also possible that your payer has its own, separate edit in place for this code pairing, which may mean that you’ll need to appeal the claim. Have the physician write a letter explaining why he performed the cryotherapy and pneumatic procedures (explaining the medical necessity for both, as well as the distinct nature of the two procedures), and send that along with a copy of the operative report when you appeal.