Ophthalmology and Optometry Coding Alert

Patients with diabetic retinopathy (DR) may require a series of laser treatments, predominantly with 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; photocoagulation), 67228 (Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation [laser or xenon arc]), or, sometimes, both. Reporting these procedures requires attention to the "one or more sessions" verbiage in code definitions as well as the number of postoperative days since the previous treatment, which eye is treated, and the diagnosis.
 
Coders must consider whether the patient has background (362.01, Diabetic retinopathy; background diabetic retinopathy) or proliferative (362.02, proliferative diabetic retinopathy) DR. These two diagnoses yield different sets of medically necessary procedures, in the viewpoint of payers, explains Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. Proliferative diabetic retinopathy almost always requires treatment, while background DR may never.
 
Although background and proliferative DR occur often in both eyes, the treatment is unilateral. Bill the appropriate laser code twice when both eyes require treatment, either on one line (67210-50) or two lines (67210, 67210-51-50; or 67210-RT, 67210-LT), depending on the payer's preference. If treating one eye, list the code once.
 
Note: Modifier -50 Bilateral procedure; modifier -51 Multiple procedures; modifiers -RT Right side and -LT Left side.

Both diagnoses involve diabetes but describe different manifestations of the disease. The most accurate diagnosis code for 67210 is retinal edema (362.83, Other retinal disorders; retinal edema).
 
If a patient's background DR is exacerbated and a small area of edema develops from leaking vessels, it may need treatment with a laser to seal off the leaking blood vessels. This is the focal laser (67210), done on a grid pattern, in a small focal area with "shots" aimed directly at the site of leakage. The best diagnosis code for focal treatment is retinal edema, not background DR. The edema is being treated, not the diabetes.
 
If a patient has proliferative DR, the leakage is more generalized and the treatment involves many more "shots" of the laser, not aimed at a specific area but spread out over the entire retina. The ophthalmologist may target certain vessels, but the treatment, called panretinal (67228), is more involved than focal treatment. Link 362.02 to it.

Coding the Initial Treatment

The conditions are usually discovered on eye examination, when an ophthalmologist is following a patient for diabetes. The retinopathy is most often first detected by extended ophthalmoscopy (92225-92226), and then fluorescein angiography (92235) further defines the extent of the leakage and which vessels are leaking.
 
For example, a patient comes in for a diabetes checkup. After performing extended ophthalmoscopy and fluorescein angiography, the general ophthalmologist determines that vessels have begun leaking and that retinal edema is present. The patient also complains of a blurry corner in her vision.
 
At this point, the general ophthalmologist may treat the patient or refer him or her to a retinologist. The treatment focal laser surgery on the area of edema in the left eye is performed. Code the initial treatment 67210-LT. Also bill an E/M service with modifier -57 (Decision for surgery) to indicate to the payer that the office visit is separately billable.

Subsequent treatments of 67210 or 67228 on the same eye within the postoperative period (90 days) are not separately billable, due to the "one or more sessions" verbiage in the code description.
 
For example, the same patient returns in a month, and the physician performs another focal laser treatment (67210-LT) for an area of edema that has developed on the same eye. Do not bill for this visit.
 
In another example, a patient is being monitored for proliferative DR of the right eye, and the ophthalmologist performs a panretinal laser treatment (67228-RT). The patient returns in seven weeks with a further problem, and the physician performs another panretinal treatment on the same eye. Do not bill for the second treatment.

When a subsequent treatment within the postoperative period is in a different eye, it is billable with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period).
 
For example, a patient returns a month after an initial treatment with 67210 of the left eye. The physician notices that the right eye has developed retinal edema and performs focal laser treatment in that eye. Report 67210-79-RT. Modifier -79 indicates that this procedure is unrelated to the first procedure; the diagnosis and treatment are the same, but the eye is different.

Along with modifier -79 in this case, the eye modifiers (-LT and -RT) are crucial. "This is a good example of why it is so important to use the eye modifiers when billing laser procedures," Roberts says. "If the -LT modifier had not been used for the first procedure and modifiers -79-RT used for the second procedure, the second procedure would look like an additional treatment on the same eye to Medicare and would be denied."
 
In another example, the patient returns three times after the initial laser treatment (67228), which took place March 1. The subsequent treatments, all on the same eye, were April 12, May 28 and June 30. The April and May treatments are not billable because they are within the 90-day postoperative period. The June treatment is billable because it was not in the 90-day postoperative period of the March 1 procedure.
 
Although the physician does not base treatment decision on coding rules, the biller must track the 90-day postoperative period. "The doctor goes by clinical necessity," says Paul Fernandes, billing manager for Long Island Vitreo Retinal Consultants, Great Neck, N.Y. "The patient has a first treatment, then comes back, may need a little more focal, may need a little panretinal, and whatever is needed the doctor does."
 
Sometimes, the ophthalmologist may opt not to bill outside of the postoperative period, Fernandes says. For example, the patient returns outside of the postoperative period perhaps four months later. The retinologist examines the eye or eyes, determines that all is well and that no retreatment is needed at this time, and sends the patient home without billing for the office visit. "The doctor is happy that the patient is doing well, and he doesn't want to bill for such a brief and simple encounter," Fernandes reports. This is partly because retinologists are used to conducting two hours of exams and tests on many of their patients.

Use modifier -79 even if the treatment is in the same eye and two different kinds of laser treatment 67210 and 67228 are performed, says Kitty Timmes, COMT, administrator for Joseph J. Timmes Jr., MD, FACS, a retinologist in Annandale, Va. If the initial treatment is for a localized retinopathy using 67210, and a subsequent treatment is for a more widespread retinopathy, bill 67228 even within the postoperative period.
 
For example, during a monitoring visit, a diabetic patient, is discovered to have left-eye retinopathy requiring 67210-LT. The patient returns in six weeks with a complaint of further visual problems. The exam reveals a generalized leakage, and the ophthalmologist performs a panretinal treatment, billing 67228-79-LT. 
 
The Correct Coding Initiative bundles 67210 and 67228 only for the day of the surgery, Roberts notes. If both are performed on the same day, bill 67228 only. However, the bundle does not apply when the procedures are performed on separate days.
 
Medical necessity must exist for performing 67210 and 67228 on separate dates. If both procedures are needed by the patient on the same date and there are no valid medical reasons to perform them on separate dates, it would be insurance fraud to perform them on separate dates just to get the additional reimbursement.
 
Some coders believe modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to be appropriate when billing 67210 followed by 67228. However, Medicare doesn't. "Do not use modifier -58 with these codes," Roberts says. "Medicare has taken the position that modifier -58 never applies to laser codes and cannot be used with them."

Photodynamic therapy (67221, Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]), in which a light-sensitive dye (trade name Visudyne) is injected into a vein and then the blood vessels of the eye are treated with a special laser, differs from 67210 and 67228 in purpose, applicable diagnosis codes and bilateral coding rules.
 
Photodynamic therapy is not used for diabetic retinopathy (DR), but rather for age-related macular degeneration (362.52, Degeneration of macula and posterior pole; exudative senile macular degeneration).
 
CPT and Medicare have developed special coding nomenclature for photodynamic therapy performed on both eyes. For bilateral therapy, do not report 67221 with modifier -50; instead, use new add-on code +67225 ( photodynamic therapy, second eye, at single session [list separately in addition to code for primary eye treatment]) in addition to 67221. Medicare will not pay 67221 with modifier -50; the primary cost of the procedure is the expensive Visudyne medication, which is injected once whether the procedure is unilateral or bilateral. The new code was created so that Medicare would not have to pay the full 50 percent it would normally pay for the second eye in a bilateral procedure.
 
Like 67210 and 67228, 67221 should be coded once even if repeated sessions are performed within the 90-day postoperative period, Timmes says.

Age-related macular degeneration (ARMD) is one of the most common causes of decreased vision after the age of 60. It is usually evident as a loss of pigment from the pigment epithelium and deposits of yellowish material in the sub-pigment epithelial layer in the central retinal zone. Abnormal new blood vessels may grow under the retina and leak fluid and blood. This is commonly called "wet macular degeneration" and can lead to permanent loss of central vision (peripheral vision is usually still intact).
 
DR involves a spectrum of retinal changes that accompany long-standing diabetes mellitus. Background retinopathy is nonproliferative and may or may not develop into proliferative retinopathy. Proliferative retinopathy consists of the growth of abnormal new blood vessels (neovascularization) on the retinal surface and accompanying fibrous tissue. Proliferative retinopathy can lead to vitreous hemorrhage, retinal detachment and severe visual loss. Anyone can get ARMD, but only diabetics get DR.
 
Photodynamic therapy is performed for ARMD; the focal and panretinal laser treatments are performed for DR. Photodynamic therapy is being experimented with for other conditions as well and eventually may be the treatment of choice for more than ARMD. However, Medicare will now pay for photodynamic therapy with 362.52 only.