Ophthalmology and Optometry Coding Alert

When mistakes during surgery lead to extra work for the physician but do not harm the patient, ophthalmology coders are often confused about when they can and cannot bill. 

Medicare's rule on physician mistakes is addressed through its coding edits, but the overriding principle is that a physician cannot benefit financially from his or her errors. The coding edit system seeks to prevent payments to physicians for repair of their mistakes. But under certain circumstances, you may appropriately bill for such repairs.

 

 

The following are examples of when you can bill for errors.

Lens fragments: Sometimes during cataract surgery, lens fragments remain in the eye. This situation requires a return to the operating room for follow-up surgery to remove the lens fragments. The code for removing the fragments depends on their size, which typically dictates the removal techniques. For example, a small fragment can often be removed through a straightforward posterior vitrectomy (67036, vitrectomy, mechanical, pars plana approach). A large fragment may require phacofragmentation in addition to posterior vitrectomy, which requires the use of 67036 and 66850 (removal of lens material; phacofragmentation technique [mechanical or ultrasonic] [e.g., phacoemulsification], with aspiration) with modifier -51 (multiple procedures) appended.

The lens-fragment removal is billable only if a second physician performs the surgery. Usually a general ophthalmologist does the original cataract surgery, and a retina specialist performs the lens-fragment removal. 

If the retinologist who removes the lens fragment is in the same group as the physician who performed the initial cataract surgery, and the group uses a common provider number for billing, the retinologist should bill 67036 (or 67036 with 66850-51) with modifier -78 (return to the operating room for a related procedure during the postoperative period). If the retinologist is not in the same group as the original ophthalmologist, he or she does not need modifier -78. 

Retrobulbar injection only: Sometimes, a physician begins a procedure but cannot complete it. Do not automatically bill the procedure and append modifier -53 (discontinued procedure). Rather, report a code for the part of the procedure performed. A typical situation is a retrobulbar block (67500*, retrobulbar injection; medication [separate procedure, does not include supply of medication]). The ophthalmologist starts the block and then can't proceed due to hemorrhaging. Instead of billing for the whole procedure (which may be a cataract procedure, any oculoplastic procedure, or various other ophthalmological procedures requiring a local block), code only for the retrobulbar block. This allows billing the planned procedure at a later date when it is actually done, preventing denials because the payer did not understand why you billed the same procedure code(s) twice with different dates of service.  

Partial cataract operation: Often, a patient is prepped for cataract extraction with intraocular lens (IOL) insertion (most commonly 66984, extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification). The ophthalmologist removes the cataract, and the patient develops a vitreous bulge. Rather than risk vitreous loss, the physician decides against the IOL insertion at that time. Although the intended procedure was discontinued, it would be incorrect to bill 66984 with modifier -53. The cataract extraction should be billed with the code that represents the method of extraction, such as phacofragmentation, 66850. 

By billing the cataract extraction code only, and not the full cataract surgery code with modifier -53, the surgeon facilitates the secondary IOL insertion claim. When he or she bills 66984, the payer won't deny the claim because it looks as if the physician already performed a cataract extraction and insertion. The claim may be rejected, however, if you billed 66984-53 for the first procedure, which includes insertion of an IOL, and 66985 (insertion of intraocular lens prosthesis [secondary implant], not associated with concurrent cataract removal) for the secondary insertion. When the IOL is implanted at a later date, if it is within 90 days (which is most common), append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to the surgical code (66985) to indicate a staged procedure.  

The above examples illustrate the principle of selecting the code that best fits the procedure performed, regardless of what was originally planned. When you must stray from standard procedures due to an unavoidable error, don't file the codes for the planned procedures. Instead, seek out the code or codes that best fit the service you performed. It is not proper coding to append modifiers to your originally planned procedure.  

 

 

Ophthalmologists will not be reimbursed for the following repairs:

Vitrectomy and cataract surgery: Vitreous loss during cataract surgery is a common iatrogenic incident. The posterior capsule may break during the surgery because the zonules are weak. An anterior vitrectomy is necessary to clear away the vitreous prior to affixing the IOL. 

Many ophthalmologists try to bill for the vitrectomy, but there is not a correct way to do so. "They would have to prove medical necessity for the vitrectomy," says Lise Roberts, vice president of Health Care Compliance Strategies, a consulting firm based in Jericho, N.Y. "The only medical necessity is that they have to do it in order to get the IOL in, and that makes it part of the cataract insertion. Medicare states that if something happens during the surgery that you have to deal with to complete the procedure, no additional coding is appropriate." 

If an ophthalmologist detects an anterior vitreous problem preoperatively requiring a vitrectomy -- and documents that problem prior to the cataract surgery -- the anterior mechanical vitrectomy and the cataract surgery would be billable. But it is not an iatrogenic complication because the vitreous problem had nothing to do with the surgery. In that instance, says Raequell Duran, president of Practice Solutions, an ophthalmology billing, coding and compliance consultancy based in Santa Barbara, Calif., bill the cataract surgery in the primary position (66984-RT or -LT) with the vitrectomy (67005 or 67010) in the second position with modifier -59 (distinct procedural service) appended. Because 67005 and 67010 are listed as components of the comprehensive code 66984 on the Correct Coding Initiative (CCI), modifier -59 is required to bill the vitrectomy.

Use modifier -59 to identify procedures and services that are not normally reported together but may be performed together under certain circumstances, Duran says. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision, or separate injury (or area of injury in extensive injuries) not originally encountered or performed on the same day by the same physician. 

 

Wound revision: It is inappropriate to bill for an iatrogenic incident when a physician revises a wound in the office suite or minor-procedure room. The code for this procedure, 66250 (revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure), does not specify that it must be performed in an operating room (OR). In fact, it states "any type ... major or minor." This does not, however, guarantee payment by Medicare when the procedure is done in the office, Duran says.

 

Medicare pays for services during the postoperative period that require a return to an OR when billed with modifier -78, Duran says. "The term 'operating room setting' includes a cardiac catheterization suite, a laser suite and an endoscopy suite. It does not include a patient's room, a minor-treatment room, a recovery room or an intensive-care unit -- unless the patient's condition was so critical there would be insufficient time for transport to an OR."