Ophthalmology and Optometry Coding Alert

Use LASIK to Guide Your PRK and PTK Coding

Published on Sat Mar 01, 2003

LASIK, PRK and PTK are three laser refractive keratoplasty procedures that have a problem: The procedures don't have CPT codes.

Laser-assisted in situ keratomileusis (LASIK), photore-fractive keratectomy (PRK), and phototherapeutic keratectomy (PTK) are three keratoplasty procedures that are considered by Medicare and many insurance companies still to be "experimental," says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. Placing procedures in the experimental category is simply a way to indicate that they have not yet shown enough consistent results, she says.

LASIK uses a laser to reduce curvature and correct nearsightedness, and because the corneal tissue has natural bonding qualities the eye heals without stitches. PRK uses a laser to treat nearsightedness and requires a preoperative consultation with a refractive surgeon to take a series of measurements and tests to determine your degree of nearsightedness and astigmatism (-1.5 to -7.0 diopters myopia with astigmatism no greater than 1.5 diopters) and to check the overall health of the eyes and to take a corneal map. And PTK is a corneal laser treatment that removes layers of corneal clouding and clears patients' vision when successful. By and large, Medicare and many insurance companies don't cover correction of vision, which is exactly what these laser procedures are designed to do, Callaway says, because they consider these treatments cosmetic.

Submitting Unlisted-Procedure Codes

What this means to you: If you combine the fact that LASIK, PRK and PTK don't have specific CPT codes to represent their services with the fact that many carriers consider these procedures experimental and cosmetic, your job as a coder just got harder. How should you handle claims for LASIK, PRK and PTK?

Your best bet is to submit the unlisted-procedure code for the anterior segment of the eye: 66999.

Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J., gives you these reasons why:

If there is no code for the procedure you are coding, proper coding provides for the use of the appropriate unlisted-procedure code rather than a code for a comparable service.

If you don't use the unlisted-procedure code, you will be unable to track how many times these procedures were performed in your practice, a piece of data that could be helpful in eventually establishing CPT codes for these procedures.

The AMA guides coders to use the unlisted-procedure codes so carriers can track the frequency of these procedures and gauge the necessity for new CPT codes

Also, you have to be careful not to misrepresent the service provided. Using an unlisted-procedure code and providing a description of the procedure will help to ensure that you don't have to return money to insurers for a service they didn't intend to cover.

Callaway advises how you should compile claims for unlisted procedures. "The most important thing is to keep your claim simple." She advocates submitting a quick cover letter without the "Dear So-and-so" noting the patient's name, any pertinent demographic information, and two to three sentences indicating the service represented by the unlisted-procedure code. "If you feel the need, you can attach supporting documentation and technical information," she adds, "but don't reinvent the wheel every time you are submitting a claim for one of these procedures; make a copy of the documentation and use it when necessary."

According to Callaway, when you submit an unlisted-procedure code claim for something as identifiable as LASIK, carriers know what it is and whether they are going to pay for the service. On the other hand, if the unlisted-procedure code represents an unusual surgery, you might need to send an operative note explaining the difference between what you did and similar procedures, she adds.

Weigh Your Alternatives to Using 66999

Some coders recommend using comparable existing CPT codes for LASIK, PRK and PTK but if you use this method, you could be asking for trouble.

"To use another code to represent [LASIK, PRK or PTK] might get you paid, but if there is an audit, those codes probably won't make the grade," Callaway says. She warns coders that the frequent use of another code to represent one of these services, e.g., using 65760 (Keratomileusis) for LASIK, may be a red flag for auditors indicating to them that something is awry with the claims. "Using another code just because it is similar is also a bad idea because what you are trying to accomplish won't be reflected in the code you choose," she adds.

In many cases, you won't be submitting a claim for these procedures to a carrier at all, Brink notes. "But that doesn't mean it is OK to use a code comparable to the service provided you should still use the unlisted-procedure code with adequate documentation."