Ophthalmology and Optometry Coding Alert

Question: Many of the oculoplastic procedures I perform have no CPT code, or have ambiguous codes. Some codes describe procedures that are less extensive than what I perform. What do you recommend?

New Jersey Subscriber

Answer: Trauma may require oculoplastic surgeons to perform reconstructive procedures or complicated blepharoplasty procedures that may seem to go beyond what is described in the CPT codes for blepharoplasty (67900-67924).

Oculoplastic techniques are found throughout the CPT book. Oculoplastic procedures include integu-mentary, musculoskeletal and other codes. For example, one ophthalmologist had to take mucosa tissue from the mouth to use as a graft in a reconstruction procedure after a traumatic injury. He used a code from the digestive system (40818, Excision of mucosa of vestibule of mouth as donor graft) not a standard code for an ophthalmologist to use.

Oculoplastic procedures can take a long time. If they are particularly difficult, you could append modifier -22 (Unusual procedural services) to represent extra work spent on a procedure. To qualify for modifier -22, a minimum of 35-40 minutes extra must be spent on a procedure. Document the extra work involved.

CMS is examining oculoplastic coding because often the procedures are coded incorrectly. For example, ophthalmologists who perform laceration repair (12011*-12018, 12051*-12057, and 13150-+13153) may not understand CPT rules for coding multiple lacerations. CPT states that you should add up the individual lacerations of the same type and code the total size. Because many ophthalmologists aren't familiar with the integumentary codes, they may code individual lacerations rather than one laceration code, which is improper coding.

The most common oculoplasty procedures performed by general ophthalmologists are eyelid procedures for conditions such as ectropion, entropion, dermatochalasis, ptosis and lesion removal. All except entropion and ectropion can be cosmetic problems only, which are not covered. However, when these conditions create a functional vision problem or a medical problem, Medicare covers treatment.

For example, if lower-eyelid ptosis (374.3) exposes the globe, ocular exposure and globe damage can result. Therefore, some local medical review policies allow payment for the blepharoplasty codes (15820 or 15821) with this diagnosis.

An ectropion means the lower lid droops so much that it turns away from the eyeball, resulting in potential damage from exposure. An ectropion repair code (67914-67917) tells the payer that the procedure is for an ectropion, not for a lower-lid ptosis that may be unattractive but doesn't pose a danger to the eye. Use ectropion (374.1x) as the primary diagnosis, with the problem caused by the ectropion, such as exposure keratitis (370.34), as the secondary diagnosis.

You should ask the patient to sign an advance beneficiary notice (ABN) if the case is borderline. If Medicare decides that the case was medically unnecessary because the functional-impairment criterion was not met, you will be unable to bill the patient without a signed ABN.

Answers to You Be the Coder and Reader Questions contributed by Lise Roberts, vice president, Health Care Compliance Strategies, Jericho, N.Y.; Raequell Duran, president, Practice Solutions, Santa Barbara, Calif.; and Michael X. Repka, MD, AAO representative to AMA CPT advisory committee.