Ophthalmology and Optometry Coding Alert

DRs and dislocated IOLs are dangerous - for coders and patients

Last month, we explained how to code for one common postoperative cataract complication, posterior capsule opacification (PCO) or after-cataracts ("Break YAG Capsulotomies From Cataract Globals and Earn an Extra $160," Ophthalmology Coding Alert, April 2005). Read on to see how our experts handle two other problems ophthalmologists face after cataract surgery - dislocated intraocular lenses (IOL) and retinal detachment.

Buckle Up for Retinal Detachment Code

Problem: Although it doesn't happen often - in fewer than 3 percent of cataract patients, according to some statistics - many ophthalmologists consider retinal detachment (RD) the most serious post-cataract surgery complication.
 
The popularity of extracapsular cataract removal, in which the vitreous gel is left undisturbed, has greatly reduced the risk of cataract surgery detaching the retina.
 
During intracapsular surgeries, however, the entire lens is removed, leaving nothing to hold the vitreous in place. The vitreous then sometimes pulls on the retina, causing tearing. And retinal tears can sometimes even be a complication of extracapsular procedures.
 
Diagnosis: ICD-9 code 361.81 (Retinal detachments and defects; traction detachment of retina).
 
Treatment: The most common procedure to repair RD is scleral buckling. The ophthalmologist relieves pressure on the vitreous by placing a silicon band around the eye, indenting it toward the detached retina.
 
Coding: Report scleral buckling with 67107 (Repair of retinal detachment; scleral buckling [such as lamellar scleral dissection, imbrication or encircling procedure], with or without implant, with or without cryotherapy, photocoagulation, and drainage of subretinal fluid), says Beth Adamski, CPC, coder for the Northern New Jersey Eye Institute in South Orange.
 
In this case, instead of appending modifier -78 (Return to the operating room for a related procedure during the postoperative period), report the service with modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) if performed during the global period of the surgery.
 
Rationale: Though it is a common practice to warn patients of retinal detachment as a complication of cataract surgery, as far as payment is concerned, Medicare considers RD unrelated to cataract surgery. "Patients can have a detachment or tear occur without having cataract surgery, and not all patients who have cataract surgery end up with a detachment or tear," says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif. "If they did, then the postoperative period for cataract surgery would include the value for caring for the typical postoperative care of a    retinal problem."

Locate Correct Modifier for Dislocated IOL

Problem: Sometimes - for instance, if the patient suffers a blow to the head - the IOL the ophthalmologist implanted during cataract surgery may move from its original position (described as "dislocation," "decentration" or "malposition") causing distorted vision.
 
Diagnosis: ICD-9 code 379.33 (Anterior dislocation of lens) or 379.34 (Posterior dislocation of lens).
 
Treatment: In some cases, a dislocated IOL can be treated with topical medicine or simply left alone. If surgery is necessary, however, the ophthalmologist will rotate the IOL through an incision, and may fix it in place with sutures.
 
Coding: CPT code 66825 (Repositioning of intraocular lens prosthesis, requiring an incision [separate procedure]) describes the surgical treatment. Report the service with modifier -78 (Return to the operating room for a related procedure during the postoperative period) if performed during the global period for the same eye, says Ginny Norrell, CPC, coder for Heaton Eye Associates in Tyler, Texas.
 
If, however, the IOL in question is in a different eye from the one that had the previous surgery, report 66825 and add modifier -79 (Unrelated procedure or service by the same physician during the postoperative period), along with modifier -RT or -LT, Norrell says.