Ophthalmology and Optometry Coding Alert

Keep on top of bilateral rules, diagnoses, and separate procedures to keep your claims straight ahead.

With 12 ocular muscles potentially involved, it can get kind of confusing for an ophthalmology coder staring down a strabismus procedure. Could one of these myths be costing your practice hundreds?

Myth: Report 67312 for Bilateral Horizontal Muscles

Reality: In strabismus surgery, the ophthalmic surgeon shortens or lengthens the muscles surrounding the eye, which changes the alignment of one or both eyes. Confusion sometimes arises when the ophthalmic surgeon resects the lateral rectus muscles of both the patient’s eyes.

Because the ophthalmologist performed a resection procedure on two horizontal muscles, 67312 (Strabismus surgery, recession or resection procedure; 2 horizontal muscles) may look correct, but don’t fall into this trap.

The strabismus surgery CPT® codes (67311-67318) describe unilateral procedures or procedures performed on one eye only, explains 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. Although the surgeon did resect two muscles, they were in different eyes, so 67312 is not correct. Instead, you should report 67311 (Strabismus surgery, recession or resection procedure; 1 horizontal muscle) bilaterally. Most Medicare carriers want you to report the entire session on one line with modifier 50 (Bilateral procedure) and a “1” in the units field.

Warning: Reporting 67312 would hurt your reimbursement in this case, and it is really an incorrect code to use for the services that were performed. In the Medicare physician fee schedule, 67311 has a “1” bilateral status indicator. That means Medicare expects you to report bilateral services and will process them for payment. You can use modifier 50 for that particular code and expect to receive 150 percent payment.

If you report 67311-50 or two instances of 67311 on two lines — for example, 67311-LT for the left eye and 67311-RT-51 (Multiple procedures) for the right — Medicare will base payment on 150 percent of the fee schedule amount for a single code.

$$$: Medicare multiplies the relative value units (RVUs) for 67311 (16.92) by the conversion factor of 35.7547, arriving at $604.97. Appending modifier 50 for the bilateral procedure means that Medicare would reimburse you 150 percent of that, giving you $907.46 (unadjusted for geographical location).

Reporting 67312, however, even though the descriptor mentions “two horizontal muscles,” will short-change you. With no bilateral pay adjustment, the RVUs for 67312 would only bring in $719.74.

Bottom line: Code 67312 is also an incorrect code to report, since it implies that two horizontal muscles in the same eye were resected, and that was not the case.

Myth: 378.xx will work for pseudostrabismus diagnoses.

Reality: An ophthalmologist may document “pseudostrabismus” if a child appears to have crossed eyes but the ophthalmologist finds no misalignment. There’s no “false esotropia” code in the ICD-9 strabismus section (378.xx) — but there is a correct way to report this condition.

Physiological characteristics of a child’s face can sometimes cause the eyes to appear crossed (esotropic) when the condition of strabismus is not actually present. In most of these cases, the correct code is 743.63 (Congenital anomalies of eyelids, lacrimal system, and orbit; other specified congenital anomalies of eyelid).

Don’t use one of the esotropia diagnosis codes, such as 378.21 (Intermittent esotropia, monocular), when the patient has false esotropia. If the test does not confirm a condition, never use a diagnosis code that indicates that the condition is present.

ICD-10: Under the ICD-10 system, you would report diagnosis code Q10.3 (Other congenital malformations of eyelid). For more ICD-10 changes for congenital eye malformation diagnoses, see the related article in this issue.

Myth: You can report transposition procedures separately.

Reality: The ophthalmologist performs transposition procedures on the right medial and right lateral rectus muscles during strabismus surgery. You may be tempted to charge CPT® +67320 twice with modifier 59 for the second transposition — but don’t, say experts.

You cannot report +67320 (Transposition procedure [e.g., for paretic extraocular muscle], any extraocular muscle [specify] [List separately in addition to code for primary procedure]) separately. This code is an add-on code, which means you must report it in addition to the code for the primary procedure.

In this case, because the ophthalmic surgeon operated on two horizontal muscles (the medial and lateral muscles) in the same eye, you would report 67312 (Strabismus surgery, recession or resection procedure; 2 horizontal muscles) as the primary procedure, and add +67320 for the transposition of the second muscle.