Ophthalmology and Optometry Coding Alert

Question: I am looking for a CPT code for plastic repair of canalicular laceration requiring silicone tubes.

Delaware Subscriber

Answer: There is only one code listed for repair of canalicular repair, which is 68700 (plastic repair of canaliculi). The code that includes in its description with insertion of tube or stent is for 68750 (conjunctivorhinostomy [fistulization of conjunctiva to nasal cavity); with insertion of tube or stent). Unless the ophthalmologist actually performed the more extensive procedure, 68750, you cannot use that code to report your repair. Also, since their is a code for repair of canaliculi, you cannot use an unlisted code to report the service. Modifier -22 is for unusual circumstances.

According to the Medicare Carriers Manual, modifier -22 is for surgeries for which services performed are significantly greater than usually required. When you submit a claim with the modifier -22, the carrier reviews the claim to determine how much additional payment should be made to you above the usual approved amount.

The down side is, you do not know in advance how much more you will be reimbursed, and the claim has to go through review, so your payment is going to be delayed. If you do decide to bill the service with the modifier -22, your documentation should include: (1) A concise statement about how the service differs from the usual; and (2) An operative report submitted with the claim. Modifier -22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days.