Ophthalmology and Optometry Coding Alert

Tip: CPT® code 67112 isn’t always for subsequent repairs.

With thousands of new detached retina cases each year – as well as a projected doubling in the number of diabetic retinopathy cases by 2050 – retinal specialists are routinely kept busy. Coders are also kept busy with CPT^® codes that can be confusing. Even the most seasoned coder may be a victim of one of these myths about coding retinal procedures

Myth: CPT^® code 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique) always represents an initial retinal detachment repair procedure and 67112 (Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair[s] using scleral buckling or vitrectomy techniques) always represents subsequent retinal detachment repairs.

Reality: This rule of thumb does not always apply, and that’s a good thing.

CPT^® codes 67108 and 67112 just don’t measure up when it comes to reimbursement. The RVUs for initial retinal detachment repair (67108) are significantly higher than the RVUs allotted to 67112: 45.39 and 37.51 respectively. In average dollar amounts, this translates into a payment of $1,631.02 for 67108 and just $1,347.87 for 67112 — a difference of $283.15.

Do use code 67108 with a modifier to code a repair of a recurrent retinal detachment when the definition of the code is met. If the surgeon performs the elements that are described in 67108, he should use that code to bill the service regardless of whether the surgery is subsequent to an initial 67108.

For example: If a patient undergoes procedure 67108 in his right eye and three weeks later he returns with retinal detachment in his left eye, you can code both procedures with 67108 (for the first procedure) and 67108-79 (for the second procedure), if the documentation indicates that both retinal detachments used the treatment method outlined by the descriptor for 67108.

Do assign code 67108 with the LT or RT modifier for both the first surgery on the right eye and LT (with 79 if during the global of the first surgery) for the left eye, advises Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “The CPT^® code is considered unilateral so it should always be submitted with the correct anatomic modifier regardless of when the surgery took place,” she says.

However: You can’t avoid using 67112 for the repair of a recurrent detached retina when your carrier has a specific policy that addresses this coding scenario, which is why you should always check your carrier’s billing policy before choosing a method of coding.

Myth: Always append modifier 58 for subsequent retinal detachment repairs.

Reality: Not always. Let’s suppose, for example, a patient undergoes a retinal detachment repair, and just two weeks later that same patient returns because the retinal detachment recurs in the same location as the first.

Under these circumstances, your instinct might tell you that you can append modifier 58 (Staged or related procedure or service by the same physician during or other qualified heath care professional during the postoperative period) to the retinal detachment repair code. However, modifier 58 can’t be used simply because another procedure is being performed to fix the initial problem.

The correct modifier for a return to the OR within the global period is 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

Call on modifier 58 when the surgeon performs a secondary surgery during the post-op period of another surgery and the subsequent procedure was planned or staged. Modifier 58 requires that you meet one of three criteria:

1. The subsequent surgery is planned prospectively at the time of the original procedure (staged)

2. The subsequent surgery is more extensive than the original procedure

3. The subsequent surgery is therapeutic following a diagnostic surgical procedure.

The example above does not meet the first criterion because the physician did not plan for the retina to detach again, it does not meet the second criterion because the first and second procedures would be valued the same, and the third criterion also does not apply to the example. Therefore, you should not append modifier 58 to code 67108 a second time under these circumstances, Mac says.

Also, according to CMS, the 58 modifier cannot be used with any procedures whose descriptors indicate “one or more sessions.”

Myth: Diabetic retinopathy procedures are inherently bilateral.

Reality: Although background diabetic retinopathy (BDR) and proliferative diabetic retinopathy (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 CPT^® codes 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], 1 or more sessions; photocoagulation) and 67228 (Treatment of extensive or progressive retinopathy, 1 or more sessions; photocoagulation) 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 2015, payment for a bilateral PRP performed in an office setting would be 150 percent of Medicare’s fee schedule amount for a single 67228 ($1016.20), leading to approximately $1524 in reimbursement.

Key: To find out if any CPT^® code is bilateral or unilateral, you can check your Medicare fee schedule. 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.

Myth: Subsequent DR treatments are separately billable.

Reality: 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.

Example 1: A 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.

Example 2: 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.