Ophthalmology and Optometry Coding Alert

2 different kinds of treatments mean 2 separately billable procedures

Coding focal laser or panretinal photocoagulation procedures more than once on the same eye within the global surgical period is a great way to experience a swift Medicare denial. However, in some clinical circumstances, you can collect for multiple procedures on the same eye with Medicare's blessing - if you follow this expert advice.
 
Medicare holds that the phrase "one or more sessions," which appears in the CPT descriptions of both procedures, covers every performance of that procedure within 90 days from the first one.
 
But not all laser treatments are equal; if the patient needs two different kinds of laser treatments to destroy lesions in the same eye, you can report and collect for both treatments.

Break Laser From Global With -79

Use modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) if the treatment is in the same eye and two different kinds of laser treatment are performed - focal laser (67210, Destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; photocoagulation) and panretinal photocoagulation (PRP, 67228, Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation [laser or xenon arc]), says Jacqueline Arriola, CPC, coder for Yuma Eye Associates in Arizona.
 
If the initial treatment is for a localized retinopathy using 67210, and a subsequent treatment is for a more widespread retinopathy, report 67228-79 even within the postoperative period, Arriola says.
 
And vice-versa, says Joy Maddox, coder for the Eye Center of North Florida in Panama City. "If a patient comes in and we do a panretinal [67228], and then a month later we do a focal laser [67210] for a retinal edema, we code both," she says. "We've actually been to a judicial review on that, and it's permissible."
 
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 National Correct Coding Initiative considers 67210 and 67228 a mutually exclusive code pair only for the day of the surgery. If both are performed on the same day, bill 67228 only. But the bundle does not apply when the procedures are performed on separate days.

Avoid the -58 Trap

The rules are different if one kind of laser treatment is followed by the same treatment in the same eye. Just because your ophthalmologist plans to perform the laser treatment in stages, don't make the common mistake of believing that you can use modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) for multiple PRP or focal laser sessions of PRP, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif. Medicare has taken the position that modifier -58 never applies to procedures with "one or more sessions" language.