Ophthalmology and Optometry Coding Alert

Nail down your anatomic knowledge now and collect appropriately later.

Orthopedic coders may think they are the only ones who have to nail down the different muscles before they can choose a code, but the reality is that ophthalmology coders will need to know the 12 muscles that are involved in strabismus surgeries. By misidentifying any of these muscles, you could forfeit your repair payments.

Consider the following quick tips to ensure that your strabismus claims are as accurate as possible.

Tip 1: Get to Know the Anatomy

Just a quick study of the eye’s anatomy could be exceedingly helpful in coding strabismus correction procedures. Which codes you report depends on the extraocular muscle or muscles the ophthalmologist addresses.

Each eye has six extraocular muscles that control the eyeball’s movement and determine the eyeball’s alignment, or in some cases misalignment. Strabismus surgery is the correction of misalignment with the potential restoration of quality visual activity.

CPT^® distinguishes the strabismus surgery codes (67311-67318) by whether the procedure involves horizontal, vertical, or superior oblique muscles.

Horizontal: The eye’s two horizontal muscles are the Lateral Rectus (LR) and Medial Rectus (MR) muscles. (The MR muscle in either eye is the one closest to the nose.) If the ophthalmologist recesses (weakens) or resects (strengthens) these muscles, report 67311 (Strabismus surgery, recession or resection procedure; 1 horizontal muscle) or 67312 (... 2 horizontal muscles), depending on the number of muscles.

Vertical: The vertical muscles are the Superior Rectus (SR) and Inferior Rectus (IR) muscles. (The SR muscle is closer to the top of the head.) If the ophthalmologist recesses or resects these muscles, report 67314 (...1 vertical muscle [excluding superior oblique]) or 67316 (...2 or more vertical muscles [excluding superior oblique]), depending on the number of muscles.

CPT^® also considers the Inferior Oblique (IO) muscle -- but not the Superior Oblique (SO) muscle-- a vertical muscle. Report 67314-67316 for recession or resection of the inferior oblique muscles.  

Superior oblique: The SO muscle wraps around the top of the eyeball. Report 67318 (Strabismus surgery, any procedure, superior oblique muscle) for procedures performed on the SO muscle.

Tip 2: Remember Modifier 50 When Warranted

The strabismus surgery codes (67311-67318) are inherently unilateral, describing procedures performed in one eye only. When codes mention more than one muscle (e.g., 67312, Strabismus surgery, recession or resection procedures; 2 horizontal muscles), CPT^® is implying that those muscles are in the same eye. Therefore, if the surgeon resects one horizontal muscle in each eye, 67312 would not be correct. In that scenario, report 67311 (Strabismus surgery, recession or resection procedure; 1 horizontal muscle) bilaterally.

Payer preferences vary on the usage of modifier 50 (Bilateral procedure). Most Medicare carriers prefer that you list the code once with the bilateral modifier appended (e.g., 67311-50), while others want you to list the procedures twice and append modifiers LT (Left side) and RT (Right side).

Medicare usually reimburses for 67311-50 based on 150 percent of the fee schedule amount for a single code. The 2016 fee schedule assigns 16.94 national unadjusted facility RVUs to 67311, which yields about $606. Code 67311-50 should reimburse $909, or 150% of $606.

However, if the ophthalmologist recesses both the lateral rectus and medial rectus muscles of the left eye, you are not coding a bilateral procedure. This is a case in which 67312 would be appropriate. CMS would reimburse this at about $722.

Hidden trap: The same rules apply to the vertical muscle codes, although the wording “two or more vertical muscles” in the definition of 67316 may lead you to think it’s a bilateral code, since there are technically only two vertical muscles in one eye.

Remember, however, that CPT^® considers the inferior oblique muscle a vertical muscle for coding purposes -- so the ophthalmologist could resect “two or more vertical muscles” in one eye if he operates on the SR, IR, and IO muscles.

Watch  out: The bilateral status is different for the six strabismus add-on codes. CMS assigns them a bilateral status of “0,” meaning that the 150 percent payment adjustment for bilateral procedures does not apply. You cannot use modifiers LT/RT (Left side/Right side) or 50 with these codes:

• +67320 -- Transposition procedure (e.g., for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to code for primary procedure)
• +67331 -- Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in addition to code for primary procedure)
• +67332-- Strabismus surgery on patient with scarring of extraocular muscles (e.g., prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (e.g., dysthyroid ophthalmopathy) (List separately in addition to code for primary procedure)
• +67334-- Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure)
• +67335-- Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery)
• +67340-- Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for primary procedure).

Tip 3: Know the Botox Codes

Report 67345 (Chemodenervation of extraocular muscle) if the physician injects botulinum toxin (trade name Botox) into the affected muscle, preventing it from contracting and allowing the opposing muscle to bring the eye into the correct position. Remember to use J0585 (Injection, onabotulinumtoxina, 1 unit) for the drug (Botox) and indicate the number of units used, including any wastage.

Here’s how: “This should be reported as two separate charge lines on the claim form,” says 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 first charge for the J0585 units used (e.g. 55 units) and the second charge line should be J0585-JW for 45 units.”

That’s because Botox comes in 100 unit vials, Mac says. “If the unused portion is used for another patient, do not report wastage on the first patient. If only 30 units is injected on the second patient, report J0585 x 30 units and J0585-JW x 15 units.”

Bottom line: Only report the wastage with the last patient to have received the Botox if more than one patient is sharing a vial of Botox. “Reporting wastage of injectable drugs that are supplied by the vial is a new focus on the OIG’s Work Plan recently released,” she added.