Ophthalmology and Optometry Coding Alert

Question: The ophthalmologist performed a YAG laser procedure to clear up a patient's after-cataracts. Two weeks after the initial YAG, the ophthalmologist had to repeat the procedure to clear up more after-cataracts. Can I report the second YAG?


Michigan Subscriber
 

Answer: You can only report one yttrium aluminum garnet (YAG) laser procedure (66821, Discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [e.g., YAG laser] [one or more stages]) performed on the same eye within the 90-day global period. The phrase "one or more stages" in the CPT definition of 66821 means that the code includes any number of subsequent YAG sessions. This is true of most laser ophthalmic procedures.

If the first YAG treatment occurs within the 90-day global period of the initial cataract surgery, remember to append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to 66821 to separate it from the 6698x global surgical packages.

Note: For more on after-cataract treatments, see "Break YAG Capsulotomies From Cataract Globals and Earn an Extra $160" in the April 2005 Ophthalmology Coding Alert.