Ophthalmology and Optometry Coding Alert

Key: The right ICD-9 codes and modifiers can bring your practice an extra $900 for multiple laser sessions A diabetic retinopathy patient usually undergoes several laser treatments. But because the CPT descriptions for those treatments say "one or more sessions," you can only code the first procedure, right?
 
Not quite, experts say. The answer depends on what kind of diabetic retinopathy (DR) the patient has, as well as what method of treatment the ophthalmologist uses and whether one or both eyes are affected. 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], one or more sessions; photocoagulation) or panretinal photocoagulation (PRP) (67228, Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation [laser or xenon arc]), says Joy Maddox, coder for the Eye Center of North Florida in Panama City. 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), says Bethany Grizzaffi, CPC, CPC-H, OCS, senior coding specialist in the department of ophthalmology at the University of Texas Medical Branch in Galveston. 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 always 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, Grizzaffi says.
 
Note: For more on ICD-9 coding for diabetic retinopathy, see "Use 2 Diabetes Codes for Sweet ICD-9 Compliance" on page 35. 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 [...]