Ophthalmology and Optometry Coding Alert

$1500 may be at stake for your practice if you report 67210 or 67228 incorrectly.

In recent years, more than 4 million people over the age of 40 had diabetic retinopathy -- and of those, 655,500 had DR severe enough to threaten their vision. This is enough to keep ophthalmologists busy with focal laser and photocoagulation treatments, which means that coders should keep busy knowing the coding rules for diabetic retinopathy treatments.

Report Edema Diagnosis for Background DR

DR patients are usually facing a series of laser treatments, with either a focal laser (67210, Destruction of localized lesion of retina [e.g., macular edema, tumors], 1 or more sessions; photocoagulation) or panretinal photocoagulation (PRP) (67228, Treatment of extensive or progressive retinopathy, 1 or more sessions; [e.g., diabetic retinopathy], photocoagulation). Sometimes, however, ophthalmologists need to use both.

To navigate the DR maze, you first have to determine the kind of DR the patient has. Background -- or nonproliferative -- diabetic retinopathy (BDR or NPDR) is represented by ICD-9 code 362.01 (Background diabetic retinopathy).

Although BDR may never require treatment, in severe cases ophthalmologists use a focal laser (67210) to treat areas of edema resulting from leaking blood vessels. Using a grid pattern, the focal laser aims directly at the leaky sites to seal them off.

However: In most cases, the ophthalmologist is treating the edema, not the diabetes. Link 67210 to ICD-9 code 362.83 (Other retinal disorders; retinal edema) instead of 362.01.

Proliferative diabetic retinopathy (PDR) (362.02, Proliferative diabetic retinopathy) usually requires treatment. Instead of using the focal laser to seal off one site at a time, ophthalmologists use PRP (67228) to target the entire retinal area. Code 362.02 is the appropriate ICD-9 code for these cases.

Code Initial Treatment Bilaterally

Although BDR and PDR occur often in both eyes, the treatments for these conditions are inherently unilateral. If the ophthalmologist treats only one eye, report the laser code only once. But when the ophthalmologist treats both eyes during one session, report the laser code twice, either on one line (67210-50) or two lines (67210-RT, 67210-50-LT), for example, depending on the payer’s preference.

Medicare has assigned both 67210 and 67228 a bilateral status of "1," meaning that if you report them bilaterally, carriers will reimburse 150 percent of the fee schedule amount for a single code (or your total actual charge for both sides, if it’s lower).

For example, in 2012, payment for a bilateral PRP performed in an office setting would be 150 percent of Medicare’s fee schedule amount for a single 67228 ($1041.89), leading to approximately $1500 in reimbursement.

Key: To find out if any CPT® code is bilateral or unilateral, you can check your Medicare fee schedule, says Sylvia Conrad, insurance coordinator with Your Eye Solution in Jacksonville, Fla. You can find the bilateral indicator in column "Z" ("Bilat Surg") of the Physician Fee Schedule spreadsheet.

Opportunity: The ophthalmologist usually discovers DR during an eye examination on a patient being followed for diabetes, and you can receive reimbursement for those diagnostic tests if you code them correctly. Extended ophthalmoscopy (92225-92226) and fluorescein angiography (92235) help to determine and localize the extent of the leakage.

Example: A patient with diabetes comes in for an ophthalmic checkup. After performing extended ophthalmoscopy and fluorescein angiography, the ophthalmologist determines that vessels have begun leaking and that retinal edema is present. The patient also complains of a blurry corner in her vision.

The ophthalmologist performs focal laser surgery on the area of edema in the left eye. Code this initial treatment 67210-LT. Also bill the appropriate level of an E/M service with modifier 57 (Decision for surgery) to indicate to the payer that the office visit is separately payable.

Resist Reporting Repeat Sessions

Subsequent treatments of 67210 or 67228 on the same eye within the 90-day global surgical period are not separately billable, due to the "one or more sessions" verbiage in the code description.

Example: The above patient returns in a month for a postoperative visit, 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 treatment.

Append Modifier 79 for Treatment in Different Eye

When a subsequent treatment within the postoperative period is in a different eye, you should code and bill this service with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

Example: The above 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.

Opportunity: Each line item should get modifier 79 if the surgeon performs more than one unrelated procedure.

Don’t miss: As is the case with modifier 79, the eye modifiers (LT and RT) are crucial. If modifier LT had not been used for the first procedure and modifiers 79 and 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.