Ophthalmology and Optometry Coding Alert

Question: Our ophthalmic surgeon performed a levator resection (67904), an entropion repair (67924) and canthoplasty on the right upper eyelid (67950). CCI bundles 67904 and 67924 as mutually exclusive, and 67950 as a component of 67924 -- but I know I can break those bundles with modifier 59. I'm confused about the sequence of codes and the proper placement of modifiers, though. What order should I list the codes in, and which codes get the modifier?

Colorado Subscriber

Answer: Before you try to report 67904 (Repair of blepharoptosis; [tarso] levator resection or advancement, external approach), 67924 (Repair of entropion; extensive [e.g., tarsal strip or capsulopalpebral fascia repairs operation), and 67950 (Canthoplasty [reconstruction of canthus]) together, you need to be sure that all three qualify for modifier 59 (Distinct procedural services).

Definition: Use modifier 59 "to identify procedures/services that are not normally reported together, but are appropriate under the circumstances," explains Medicare in an article available at www.cms.hhs.gov/NationalCorrectCodInitEd. Appropriate uses Medicare gives for appending modifier 59 include:

• different session or patient encounter

• different procedure or surgery

• different site or organ system

• separate incision/excision

• separate lesion or separate injury.

Resort to modifier 59 "only if no more descriptive modifier is available," warns Medicare. If you're sure that modifier 59 applies, sequence the codes with the highest reimbursement first. According to the 2010 fee schedule, Medicare assigns 18.32 relative value units (RVUs) to 67904, 14.67 to 67924, and 14.42 to 67950. So, you would code 67904 first, followed by 67924-59 and 67950-59.

Don't miss: You should also append modifier LT (Left side) or RT (Right side) to paint a clear picture of why the unbundling may be appropriate. Again, clear documentation is necessary to support that the ophthalmologist met the criteria for unbundling. Never append modifier 59 simply because the modifier indicator for the edits is "1." First and foremost, determine whether one or more of the above circumstances is present.