Ophthalmology and Optometry Coding Alert

Keeping track of all the variables involved can be challenging.

According to the Centers for Disease Control and Prevention (CDC), 4.2 million Americans suffer from diabetic retinopathy (DR), and 655,000 have vision-threatening retinopathy. It is the leading cause of new cases of blindness in working-age adults. Early detection and proper treatment are critical to your patients — and proper coding is critical to your practice.

If you’re wondering whether your DR coding skills are top-notch, take the following quiz and test your skills.

Get to Know the Diagnosis Codes

Question 1: Which ICD-10-CM code would you report as the primary diagnosis for a patient with moderate proliferative diabetic retinopathy in the right eye as a result of uncontrolled type 2 diabetes? The patient does not have macular edema.

• A. E11.311
• B. E11.3391
• C. E11.3392
• D. E11.37X1

Answer 1: B. The 2022 ICD-10-CM guidelines direct you to sequence diabetes codes “based on the reason for a particular encounter.” Once you locate diabetic retinopathy in the ICD-10-CM code book, you’ll be able to narrow it down based on the level of retinopathy (mild, moderate, severe) and which eye is affected (left, right, bilateral). You’ll also determine whether the patient had macular edema, and in this case, that condition is not present. Therefore, your primary diagnosis code will be E11.3391 (Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye).

However, you won’t stop there. You’ll see that the notes under E11.3391 in your ICD-10-CM code book indicate that you should use an additional code to identify control, as follows:

• Z79.4 (Long term (current) use of insulin)
• Z79.84 (Long term (current) use of oral hypoglycemic drugs or oral antidiabetic drugs)

If your patient takes medication to control their diabetes, add one of these codes to your claim following E11.3391.

Can You Code Focal Laser Service?

Question 2: For a severe case of background diabetic retinopathy, the ophthalmologist uses a focal laser to treat areas of edema resulting from leaking blood vessels. What CPT^® code would you report?

• A. 67210
• B. 67218
• C. 67220
• D. 67228

Answer 2: A. DR patients are usually facing a series of laser treatments, with either a focal laser (67210, Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation) or panretinal photocoagulation (PRP) (67228, Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation), also known as “scatter treatment.”

Background — or nonproliferative — diabetic retinopathy (BDR or NPDR) may never require treatment, but in severe cases, ophthalmologists may 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-10-CM code H35.81 (Retinal edema) instead of the E11 code.

In cases of proliferative diabetic retinopathy, instead of using the focal laser to seal off one site at a time, ophthalmologists would use PRP (67228) to target the entire retinal area.

Select the Right Number of Units for Photocoagulation

Question 3: The ophthalmologist uses pan-retinal photocoagulation to treat DR in both eyes. You would report:

• A. 1 unit of 67210.
• B. 1 unit of 67210 with a modifier appended.
• C. 1 unit of 67228.
• D. 1 unit of 67228 with a modifier appended.

Answer 3: B. 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, Bilateral procedure) or two lines (67210-RT, Right side, 67210-50-LT, Left side), 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).

Take Global Periods Into Account

Question 4: On May 15, the ophthalmologist performs focal laser surgery on the area of edema in the left eye. On June 15, the patient returns for a postoperative visit, and the ophthalmologist performs another focal laser treatment for an area of edema that has appeared in the same eye. For the June 15 procedure, you would report:

• A. 67210-LT.
• B. 67210-59-LT.
• C. 67210-79-LT.
• D. You would not bill for this procedure.

Answer 4: D. 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.

However: When a subsequent treatment within the postoperative period is in the fellow eye, you should code and bill this service with modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period).

In this scenario, if the patient returned a month after an initial treatment with 67210 of the left eye, and the physician notices that the right eye has developed retinal edema and performs focal laser treatment in that eye, you would 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 are used for the second procedure, the second procedure could look like an additional treatment on the same eye to Medicare and would be denied.