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, [...]