Ophthalmology and Optometry Coding Alert

Question: We have a problem regarding the wording in the CPT book for primary strabismus codes 67311 through 673138. It states in parentheses, patient not previously operated on. When billing 67332, for example, it states this code should be used in addition to 67311-67318, and yet 67332 is regarding a patient who has had previous surgery. We fight for payment on this constantly.

Deanna C. Fisher, Ophthalmic Associates
Las Vegas, NV

Answer: This problemand it is a very confusing onewas solved in CPT 1999. The old version of CPT made it possible for many commercial payersnot usually Medicareto use the language as a way of denying payment for the codes for the muscle procedures (67311-67318), explains Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY, and a specialist in ophthalmology coding. The primary strabismus procedures are 67311 (strabismus surgery, recession or resection procedure; one horizontal muscle), 67312 (strabismus surgery, recession or resection procedure; two horizontal muscles), 67314 (strabismus surgery, recession or resection; one vertical muscle [excluding superior oblique]), 67316 (two or more vertical muscles [excluding superior oblique]), and 67318 (strabismus surgery, any procedure, superior oblique muscle).

The RBRVS units for these primary codes do not include values for the add-on services of 67331 (strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles), 67332 (strabismus surgery on patient with scarring of extraocular muscle [e.g., prior ocular injury, strabismus or retinal detachment surgery] or restrictive myopathy [e.g., dysthyroid ophthalmopathy]), 67334 (strabismus surgery by posterior fixation suture technique, with or without muscle recession), and 67335 (placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s)). The add-on codes have a plus sign (+) in front of them in the CPT book to identify that they are to be used in conjunction with other codes. These strabismus add-on codes are to be used in conjunction with codes 67311 through 67318.

If payerssome are very slow to load the new codes each year, and may totally ignore new verbiageare using RBRVS as the basis for their fee schedule, says Roberts, you should explain to them that CPT has deleted the language indicating that 67311 is for patient not previously operated on and that the RBRVS scale does not include values for the add-on codes in the values for the primary muscle procedure codes. In addition, you could point out that Medicare has always handled the payment of the add-on codes separately because of the unit value issue. If necessaryand it may beyou should send them the corrected version of the CPT book as well. This will clearly show that you should be paid for the 67311-67318 series, in addition to the add-on code.