Ophthalmology and Optometry Coding Alert

Question: My ophthalmologist removed a conjunctival lesion. To repair the conjunctiva post- removal, he rotated the edges of the conjunctiva together and sutured up the removal hole. I don't think that I can code for the repair since it has to be closed anyway, but it is listed on the report as a separate procedure (conjunctivoplasty). Should this be coded separately?

Illinois Subscriber

Answer: The National Correct Coding Initiative (NCCI) edits list conjunctivoplasty (68320, Conjunctivoplasty; with conjunctival graft or extensive rearrangement) as a "comprehensive" code.

When codes are listed as comprehensive, they have corresponding lists of "component" codes, procedures that  payers consider included in the fee for the comprehensive code.

The lesion removal codes - 68110 (Excision of lesion, conjunctiva; up to 1 cm), 68115 (Excision of lesion, conjunctiva; over 1 cm) and 68130 (Excision of lesion, conjunctiva; with adjacent sclera) - are listed as "components" of 68320, so if they are performed on the same day and billed, 68320 will be paid and the excision code will be denied as an NCCI edit.

Two things to remember:

1. Medicare carriers abide by the NCCI edits, but private and third-party payers can choose whether or not to use them. So when submitting a claim to a non-Medicare carrier, list all of the surgical procedures that the ophthalmologist performed and let the payer determine how to pay you.

2. The descriptor for procedure code 68320 states "extensive rearrangement." Your physician will need to determine whether to report just the excision code if the conjunctival rearrangement did not involve that much work, or to report only the rearrangement (this only applies to Medicare).

The NCCI edits only apply when multiple procedures are performed on the same day.