Ophthalmology and Optometry Coding Alert

Knowing the difference can mean $262 to your practice.

Two retinal repair codes top coders' charts as the most difficult to use: 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) and 67112 (... by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair[s] using scleral buckling or vitrectomy techniques).

The confusion surrounding CPT codes 67108 and 67112 is attributable to the similarity in the language used in their descriptors and the failure of CPT to instruct coders onwhich code should be used for recurrent repairs. As a general rule, coders think of CPT code 67108 as representing an initial retinal detachment repair procedure and 67112 as representing subsequent retinal detachment repairs. But 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: 40.55 and 33.42 respectively. In average dollar amounts, this translates into a payment of $1,495.20 for 67108 and just $1,232.29 for 67112 -- a difference of $262.91.

Take Our Advice for 67108

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 when the second retinal detachment repair is performed if the work meets the following:

• The second 67108 procedure is performed outside the 90-day global period of the initial 67108 procedure; or
• The second 67108 procedure is performed by a physician who is not a member of your practice.

For a more complicated scenario, let's suppose 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 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 following initial procedure for a related procedure during the postoperative period), notes Maggie  M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City.

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, notes Donna Pisani, provider outreach and education consultant with Medicare contractor National Government Services. 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 cannot append modifier 58 to code 67108 a second time under these circumstances.

Also, according to CMS, the 58 modifier cannot be used with any procedures whose descriptors indicate "one or more sessions." This caveat means 58 should never be used with any of the following codes:

• 65855 -- Trabeculoplasty by laser surgery, 1 or more sessions (defined treatment series)
• 66761 -- Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) (1 or more sessions)
• 66762 -- Iridoplasty by photocoagulation (1 or more sessions) (e.g., for improvement of vision, for widening of anterior chamber angle)
• 67141 -- Prophylaxis of retinal detachment (e.g., retinal break, lattice degeneration) without drainage, 1 or more sessions; cryotherapy, diathermy
• 67145 -- ... photocoagulation (laser or xenon arc)
• 67208 -- Destruction of localized lesion of retina (e.g., macular edema, tumors), 1 or more sessions; cryotherapy, diathermy
• 67210 -- ... photocoagulation
• 67218 -- ... radiation by implantation of source (includes removal of source)
• 67220 -- Destruction of localized lesion of choroids (e.g., choroidal neovascularization); photocoagulation (e.g., laser), 1 or more sessions
• 67227 -- Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), 1 or more sessions; cryotherapy, diathermy
• 67228 -- ... photocoagulation (laser or xenon arc).

Use 67112 When Instructed by Your Carrier

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.