Ophthalmology and Optometry Coding Alert

Question: A diabetic patient underwent focal laser treatment and panretinal photocoagulation (PRP) in both eyes. The ophthalmologist first performed focal laser on the right eye, and two weeks later performed PRP on the same eye. Four weeks after that, he did the focal laser on the left eye, and then three weeks later PRP on the left eye. The patient returned for a follow-up evaluation six months later, and our ophthalmologist noted clinically significant macular edema in both eyes and scattered intraretinal hemorrhages and exudates in the left eye. He then performed the focal laser on the right eye and two weeks later PRP on the left eye. A month later, he did the PRP on the right eye. How should I code for this?

Georgia Subscriber

Answer: Medicare considers both of the procedures you reference - focal laser (67210, Destruction of localized lesion of retina, one or more sessions; photocoagulation) and PRP (67228, Destruction of extensive or progressive retinopathy, one or more sessions; photocoagulation) - major procedures. Both have 90-day postoperative periods. They also both have in their code descriptors the phrase "one or more sessions," which means you can perform the procedures multiple times - but you may only bill it once per eye per 90 days.
However, Medicare does allow payment for 67210 followed by 67228 on the same eye within the 90 days.

Key: In this scenario, you have two distinct 90-day global periods. For the first set of procedures, report: