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 fee schedule amount for a single code (or your total actual charge for both sides, if it's lower).
 
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.
 
Example: A patient comes in for a diabetes checkup. After performing extended ophthalmoscopy and fluorescein angiography, the ophthalmologist determines that vessels have begun leaking and that retinal edema is present. The patient also complains of a blurry corner in her vision.
 
The ophthalmologist performs focal laser surgery on the area of edema in the left eye. Code this initial treatment 67210-LT. Also bill an E/M service with modifier -57 (Decision for surgery) to indicate to the payer that the office visit is separately billable.

Resist Reporting Repeat Sessions

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, says Elizabeth Borgen, coder for the North Dakota Eye Clinic and Surgery Center in Grand Forks.
 
Example: The above patient returns in a month for a postoperative visit, 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.

Append Modifier -79 for Treatment in Different Eye

When a subsequent treatment within the postoperative period is in a different eye, you should code and bill this service with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period),  Maddox says.
 
Example: The above patient returns a month after an initial treatment with 67210 of the left eye. The physician notices that the right eye has developed retinal edema and performs focal laser treatment in that eye. 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.
 
"Also, since the visit focused on the examination and treatment of the fellow eye, not the postoperative eye, bill the level of visit documented appended with the -57 modifier if the decision to perform the laser procedure was made during that day's visit," says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.
 
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-RT used for the second procedure, the second procedure would look like an additional treatment on the same eye to Medicare and would be denied.