Ophthalmology and Optometry Coding Alert

Question: Our provider performed a right medial rectus disinsertion/reinsertion of the muscle for nystagmus. Can I still use 67311 if he did not recess or resect the muscle?

North Carolina Subscriber

Answer: CPT^® distinguishes the strabismus surgery codes (67311-67318) by whether the procedure involves horizontal, vertical, or superior oblique muscles. Since the procedure you describe was performed on the right medial rectus muscle, which is one of the horizontal muscles, 67311 (Strabismus surgery, recession or resection procedure; 1 horizontal muscle) would be an obvious code choice.

However, according to your documentation, the provider did not recess or resect, so you should report 67399 (Unlisted procedure, extraocular muscle), since there is no specific code that defines the strabismus surgery procedure without recession or resection.