Ophthalmology and Optometry Coding Alert

Question: A patient has proliferative diabetic retinopathy with traction retinal detachment. The doctor performed pars plana vitrectomy, pars plana lensectomy, membrane peel, air fluid exchange, injection of silicone oil and endolaser PRP (panretinal photocoagulation). What codes should we use?

Indiana Subscriber

Answer: Although several individual codes describe those procedures, Medicare says when one code can be used to describe what was performed, that code is to be used. As an example, there are individual codes for pars plana vitrectomy, lensectomy, air fluid exchange, injection of silicone oil and endolaser, but one code includes all of those services to repair a retinal detachment: 67108 (repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique).

If you were to use the individual codes instead, Medicare would consider that practice unbundling, which is a type of billing fraud. Code 67108 represents all of the services performed except for the membrane peeling. In addition to coding 67108 you can use 67038 (vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping), which is the only part of the procedures performed that is not included in 67108. It may seem to you that you are double billing because both 67108 and 67038 have vitrectomy in their language, but this problem has been addressed by HCFA. The agency reviewed this issue at the request of the Retina, Macula and Vitreous Society a few years ago and concluded that because of the multiple-procedure payment rule, the second procedure billed will be reduced by 50 percent anyway, so physicians are not being paid twice for the vitrectomy portion of the code. To bill multiple procedures, modifier -51 (multiple procedures) is appended to all procedures performed other than the primary or first procedure billed.

For a brief time recently, it appeared that 67038 was bundled into 67108 under a Correct Coding Initiative (CCI) update. This was fought by the American Academy of Ophthalmology and was rescinded by HCFA as a bundle almost as soon as it appeared.

For other payers you could use the -52 modifier on the second procedure to indicate that you are not including the vitrectomy in these codes. Do not reduce the fee, because the carrier will. Note that 67108 includes scleral buckling if performed, but does not require it for the use of the code.

As a final note, even though 67108 is the primary procedure performed, when submitting your claim you should always list the code with the highest reimbursement first. In this case, bill 67038-LT or -RT (to indicate left side or right side) in the primary position, and 67108-51-LT [...]