Ophthalmology and Optometry Coding Alert

Most eye care physicians would agree that they sometimes find it necessary to perform retinal detachment repairs on patients who have already undergone similar procedures. Although it may be straightforward to justify why repeat surgeries were performed, the coding may not be simple, eye care coders say.

Scenario: The ophthalmologist repairs a retinal detachment using scleral buckling. The patient had a prior retinal detachment repair on the same eye but the retina detached again, requiring this new surgery.

Check out the following three steps to determine how to code this procedure note.

1. Consider Your Options

Veteran coders were accustomed to using now-deleted code 67112 (Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair[s] using scleral buckling or vitrectomy techniques) for repeat retinal repairs. The descriptor specifically noted that it was to be used “on patient having previous ipsilateral retinal detachment repair…” However, once that code was deleted four years ago, CPT^® never issued a replacement that referred to repeat procedures.

Instead, coders were instructed to report the code that most appropriately describes the surgeon’s documentation. “Code 67112 is deleted in the CPT^® 2016 code set as an obsolete procedure,” the AMA said in the June 2016 edition of CPT^® Assistant. “It combined scleral buckling with an unspecified vitrectomy that could be more accurately reported with other more specific codes.” Even though this change took place years ago, many coders still lament the code’s absence.

In reality, your code choices should center only on the service the ophthalmologist documents, rather than considering whether the surgery was a repeat procedure.

Although many coders go straight to 67108 (Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique) for retinal repairs, keep in mind that this code refers to a procedure performed “with vitrectomy,” and our example does not include any mention of vitrectomy.

Therefore, your best bet is 67107 (Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid), which mentions the retinal detachment repair via scleral buckling, but does not include any discussion of vitrectomy.

2. Determine Whether Modifiers Are Necessary

Once you nail down the correct code, you’ll determine whether any modifiers are necessary to tell the payer that you performed a repeated surgery.

Although you may want to reach for a modifier to reflect a repeat procedure, you may not need one to code a repair of a recurrent retinal detachment when the definition of the code is met. That’s because the code itself tells the insurer what you performed, and the fact that it was a repeat is typically irrelevant. The one caveat to that rule, however, occurs if you perform the second procedure during the global period of the previous retinal detachment repair. In that case, a modifier will typically be necessary.

For example: A patient undergoes retinal repair for the right eye and you report 67107, but three weeks later he returns with retinal detachment in his left eye. You can code 67107 for the first procedure and 67107-79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) for the second procedure, if the documentation indicates that both retinal detachments used the treatment method outlined by the descriptor for 67107. The modifier is necessary since 67107 has a 90-day global period, and the second service was required within that 90-day period.

Don’t forget: You should also assign the LT (Left side) and RT (Right side) modifiers when applicable. So, for the above case, your coding will look like this:

First procedure: 67107-RT

Second procedure: 67107-LT-79

3. Use Caution With Modifier 58

For a more complicated scenario, let’s suppose a patient undergoes a retinal detachment repair and the practice reports 67108, and just two weeks later that same patient returns because the retinal detachment recurs in the same location as the first, when 67108 must be reported a second time.

Under these circumstances, your instinct might tell you that you can append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to the retinal detachment repair code. However, modifier 58 can’t be used simply because another procedure is being performed to fix the initial problem.

Call on modifier 58 when the surgeon performs a secondary surgery during the postop period of another surgery and the subsequent procedure was planned or staged. Modifier 58 requires that you meet one of three criteria:

1. The subsequent surgery is planned prospectively at the time of the original procedure (staged)
2. The subsequent surgery is more extensive than the original procedure
3. The subsequent surgery is therapeutic following a diagnostic surgical procedure.

The example above does not meet the first criterion because the physician did not plan for the retina to detach again; it does not meet the second criterion because the first and second procedures would be valued the same; and the third criterion also does not apply to the example. Therefore, you cannot append modifier 58 to code 67108 a second time under these circumstances.

The correct modifier for a return to the OR within the global period is 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). Therefore, to report the second procedure, you’ll report 67108-78.