Ophthalmology and Optometry Coding Alert

Knowing what's not included in the global package can mean $1,173 in additional income

When your ophthalmologist performs glaucoma surgery, he often has to take care of postsurgical complications. Some of that work is included in the global surgical package of the glaucoma surgery - but not all. Knowing what you can and can't code for could mean the difference between deserved reimbursement and costly denials.

Look for Good Things Outside Global Packages

Glaucoma surgery requires attention, special training and skill. But problems - from patient discomfort to vision loss - can arise in even the most routine of cases, says Regan Bode, CPC, OCS, clinic administrator at the Northwest Eye Clinic in Bellingham, Wash.
 
The global surgical package includes normal, uncomplicated follow-up care, according to the definition in the CPT manual. However, certain services associated with surgery are not considered part of the package and are reimbursed separately, Bode says. In Medicare's regulations, the global surgery package does not include the following follow-up services:

Treatment for postoperative complications requiring a return trip to the OR. Report these procedures with modifier -78 (Return to the operating room for a related procedure during the postoperative period) appended. Medically necessary return trips to the OR for any reason without regard to fault are reimbursed separately - but at a reduced rate, Bode says. "Under the modifier -78 rules, the post-op clock isn't reset," she says, "so payment for re-operations is the value of the preoperative (10 percent) and the intra-operative (70 percent) service for the CPT code without payment for additional post-op care (20 percent) beyond what was included in the first procedure."

Example #1: Five days ago, the ophthalmologist performed trabeculectomy (65855, Trabeculoplasty by laser surgery, one or more sessions [defined treatment series]) on a patient who now presents with hyphema. If the hyphema doesn't resolve on its own, the ophthalmologist will wash out the anterior chamber in the OR.

Code 65815 (Paracentesis of anterior chamber of eye [separate procedure]; with removal of blood, with or without irrigation and/or air injection) describes this second operation. Append modifier -78 to the code to indicate that the washout relates to the trabeculectomy because hyphema is a complication of the initial surgery. Be sure to use the diagnosis code for hyphema (364.41, Vascular disorders of iris and ciliary body; hyphema) when submitting the claim to the carrier for payment, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, Clearwater, Fla.

Example #2: Yesterday, the ophthalmologist performed a trabeculectomy on the patient, and today the patient presents with suprachoroidal hemorrhage and excruciating pain. The ophthalmologist needs to drain the suprachoroidal fluid in the OR.

Code 67015 (Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach [posterior sclerotomy]) describes this second operation. While performing the aspiration, the ophthalmologist injects balanced salt solution into the anterior chamber to raise the IOP. Again, append modifier -78 to the code to indicate that the drainage relates to the trabeculectomy because suprachoroidal hemorrhage is a complication of the initial surgery.

Hidden trap: Don't report 66020 (Injection, anterior chamber of eye [separate procedure]; air or liquid) because this step is an incidental aspect of the draining suprachoroidal fluid and subject to the separate-procedure rule, Bode says.

"Medicare does not pay based on the 'separate procedure' indication in a CPT description," says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif. "If the National Correct Coding Initiative lists 66020 as a component of the comprehensive code of 67015, then the NCCI listing would be the reason not to report it, not the CPT language."

Additional procedure prospectively planned as a staged procedure. Report staged procedures with modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) appended. A staged procedure is planned prospectively at the time of the original procedure, or is a greater procedure following a lesser procedure, or a therapeutic procedure following a diagnostic procedure, Duran says.

"Under the modifier -58 rules, the post-op clock is reset and the ophthalmologist receives reimbursement based on the full allowable amount, not just the pre- and intra-operative component," Bode says.

Example: The patient is predisposed to inflammation and scarring, so the glaucoma surgeon plans to use two antimetabolites: Mitomycin C and 5-FU. The ophthalmologist uses Mitomycin C at the trabeculectomy and plans the subconjunctival injections of 5-FU for the post-op period. The ophthalmologist will do these 5-FU injections in his office.

Code 68200 (Subconjunctival injection) describes the injection component of the 5-FU injection. Append modifier -58 to show that these injections were a staged procedure. And use code J9190 (Fluorouracil, 500 mg) to report the supply of the 5-FU medication.

"It's quite common to give as many as five to ten injections during the first two weeks of the post-op course," Bode says. "The reimbursement ramifications are significant because of repeated charges."

More extensive procedure after the failure of a less extensive procedure. If a less extensive procedure fails and the patient requires a more extensive procedure, the payer reimburses for the second procedure separately. File your claim for the second surgery with modifier -58 appended. No reduction is made to the reimbursement, says Mary Schwall, CPC, clinical practice specialist at the Yale Eye Center in New Haven, Conn. "The only difference is that it resets the post-op clock," she says.

Example: Nine weeks ago, the ophthalmologist performed primary trabeculectomy. The surgery failed despite the use of antimetabolites. The same ophthalmologist returns to the OR and performs another trabeculectomy. Since scar tissue is present, report 66172 (Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma). Append modifier -58 to the second trabeculectomy to signify that the second trabeculectomy relates to the first surgery and is more extensive than the original procedure. (The unadjusted 2005 RVUs for 66172 are 30.95, leading to $1,173 when multiplied by the 37.8975 conversion factor.)

Supply of medications that can't be self-administered. Injectable medications administered by the ophthalmologist are covered outside the global period, but the act of administration may not be.

Example: Six days ago, the ophthalmologist performed trabeculectomy on the patient, and today the patient presents with elevated IOP and a failing bleb. The ophthalmologist injects 5-FU about 1 cm away from the bleb site. This is done in the ophthalmologist's office.

This case is different from the previous case in subtle ways, Bode says. Medicare's global surgery package includes "all additional medical or surgical services required of the ophthalmologist during the postoperative period of the surgery because of complications which do not require additional trips to the OR," she says.

You shouldn't file a claim for administering the injection, because it's a procedure that doesn't require a return to the OR, Bode says. "Modifier -58 is not appropriate because the injection was not preplanned or staged," she says. "Without a modifier, the claim will be bundled with the original trabeculectomy." You can still code for the 5-FU with J9190.