Ophthalmology and Optometry Coding Alert

Question: To save time in the operating room, I bring malignant lesions to the office either the day before or in the morning of an operative session. I excise the lesion, ensuring I excise the entire neoplasm, and send it to the local hospital pathology department for frozen section margin control. I then perform the reconstruction in the operating room either the next day or that afternoon. What is the best way to code these procedures if the procedure is a wedge resection (67961 or 67966) for an eyelid lesion?

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Answer: You should first report a code from 11640-11646 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips ...) for the office excision, based on the lesion size. Then, report the appropriate reconstruction code from 67950-67975, depending on the actual reconstruction procedure.

If you perform the reconstruction on the same day or next day, append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the reconstruction procedure code to indicate the staged procedure.

Watch out: You may need to append modifier 59 (Distinct procedural service) to 11640-11646 to designate the separate surgical session on the same day if you're coding 11640-11646 with 67961 or 67966 on the same day. Although the Correct Coding Initiative (CCI) bundles 11640-11646 with 67961 and 67966, you can appropriately unbundle for the separate surgical sessions. As always, you must have documentation in the medical record to support all services rendered.