Ophthalmology and Optometry Coding Alert

Question: The retinologist meets with a patient and recommends a focal laser treatment, which the patient schedules for the following week. We report a consult for this visit. On the day of the scope, the retinologist re-examines the patient, answers questions, etc. The time spent prior to starting the procedure is 10 minutes. Should we bill this service as 99212-25 on the same day as procedure 67210?


Colorado Subscriber


Answer: In this case, you won't report a separate E/M (even a low-level visit such as 99212, Office or other outpatient visit for the evaluation and management of an established patient ...) with the focal laser (67210, Destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions, photocoagulation).

Remember: All procedures include an "inherent" E/M component, according to CPT and CMS guidelines. To qualify as a separately billable service, any E/M the physician provides must be both significant and separately identifiable from the E/M component already included in the primary procedure.

Surgical procedures have global surgical packages that define preoperative, intraoperative and postoperative work. Code 67210 is considered a major procedure, with a preoperative period that includes the day before the surgery, the surgery itself, and 90 postoperative days.

If the retinologist had provided the initial E/M service and the focal laser on the same day or on the day before, you could report the E/M service separately using modifier 57 (Decision for surgery). In this case, however, the retinologist has already conducted a full E/M workup prior to the focal laser and decided to perform the surgery, and you have already coded for that work. 

At the time of the focal laser, if the patient has no new complaint or substantial change in her condition that prompts a new history, exam and medical decision-making process, you should not report a second E/M service. Report only 67210 for this visit.