Ophthalmology and Optometry Coding Alert

With more than 10,000 changes, you could spend hours weeding through the latest round of Correct Coding Initiative (CCI) edits. But we've already done the deciphering for you. Take a look at the ophthalmology edits you need to incorporate into your coding this year.

If your ophthalmologist performs retina surgeries, you welcomed the new vitrectomy codes with open arms in January. CCI hits these new codes hard in version 14.0, however.

The latest CCI update bundles new vitrectomy code 67041 (Vitrectomy, mechanical, para plana approach; with removal of preretinal cellular membrane [e.g., macular pucker]) with 67030 (Discission of vitreous strands [without removal], pars plana approach) and 67031 (Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery [one or more stages]). The edit indicates that CCI now considers these codes mutually exclusive.

Good news: Both bundles have a modifier indicator of 1, which means you can bypass an edit using a modifier under the appropriate circumstances, says Maggie M. Mac, CMM, CPC, CMSCS, CCP, ICCE, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla. "In general, these circumstances relate to separate patient encounters, separate anatomic sites (e.g., right eye and left eye) or separate specimens. For ophthalmology services, most edits with a modifier indicator of 1 allow reporting of the two bundled services when one service is performed on one eye and a CCI-bundled service is performed on the contralateral eye."

During the procedure described with 67041, the ophthalmologist removes the central vitreous and shaves the vitreous "as close as is safe to the vitreous base while replacing the vitreous with a fluid to maintain intraocular pressure," says Regan Bode, CPC, CPC-EM, ACS-EM, OCS, product manager for Custom Coding Books in Seattle and founder of Eyecoding.net. "Since this code includes removing the vitreous already, it seems appropriate that other codes for removing or dissecting small areas or amounts of vitreous are bundled within 67041."

In addition: CCI also bundles 67041 with 36000, 36410, 37202, 62318, 62319, 64415-64417, 64450, 64470, 64475, 65800-65815, 66830, 66840, 66852-66940, 67005-67028, 67036, 67101-67107, 67110-67112, 67120-67145, 67500, 67515, 68200, 69990, 90760, 90765, 90772, 90774 and 90775. All of these bundles have a modifier indicator of 1 except the bundle between 67041 and 69990. That bundle's modifier indicator is 0, which means you can never bypass the edit and separately report the bundled services, Mac says.

"Keep in mind that although a provider may perform two procedures that cannot be reported together based on a CCI edit, there is hope. If the procedure performed qualifies as 'substantially greater than typically required,' the physician may be able to report the column 1 code with modifier 22 (Increased procedural services)," Mac says. "Documentation in the medical record must support the substantial additional work and be available in the event of a carrier review."

"These are all deemed 'components' of 67041, meaning they are considered integral parts of the comprehensive procedure," Bode says. "If you look at these codes, some of them are common items like injections (IM) or use of the microscope, which are already part of your main procedure. Others are deemed smaller components of the comprehensive code that you are billing."

Code 67041 isn't the only vitrectomy code CCI targeted with new bundles. When your ophthalmologist repairs a retinal detachment (67110, Repair of retinal detachment; by injection of air or other gas [e.g., pneumatic retinopexy]), you cannot also report 67036 (Vitrectomy, mechanical, pars plana approach), 67039 (... with focal endolaser photocoagulation) or 67040 (... with endolaser panretinal photocoagulation). CCI states that these codes are mutually exclusive and bundles them with a modifier indicator of 1.

You should report 67039 when your ophthalmologist treats minor retinal problems using focal endolaser photocoagulation, Bode says. You'll use 67040 when the physician treats larger retinal problems with endolaser panretinal photocoagulation.

"Both of these can address retinal detachments, but in a different method than 67110," Bode adds. "Physicians would be using one technique or another to resolve a retinal detachment. Code 67110 typically involves the physician injecting the eye with air or another gas to push the detachment back into place. Code 67036 requires removing and replacing the vitreous, which can achieve similar results to 67110."

More edits: CCI also bundles 67039 and 67040 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). Carriers that follow CCI will consider these codes bundled with a modifier indicator of 1. You'll also now have to consider 67040 bundled with 67112 (... by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair[s] using scleral buckling or vitrectomy techniques), also with a modifier indicator of 1.

Why: "Similar to the above situation, 67039-67040 repair the retinal detachment internally, while 67107 repairs the detachment externally," Bode says. Your ophthalmologist would use one or the other to repair a detachment, so you would rarely report both in the same session.

New vitrectomy codes 67042 (Vitrectomy, mechanical, para plana approach; with removal of internal limiting membrane of retina [e.g., for repair of macular hole, diabetic macular edema], includes, if performed, intraocular tamponade [i.e., air, gas or silicone oil]) and 67043 (... with removal of subretinal membrane [e.g., choroidal neovascularization], includes, if performed, intraocular tamponade [i.e., air, gas or silicone oil] and photocoagulation) don't escape CCI's grasp. These codes now bundle with 36000, 36410, 37202, 62318, 62319, 64415-64417, 64450, 64470, 64475, 66830, 66840, 66852-66940, 67025, 67036, 67107, 67110-67112, 67500, 69990, 90760, 90765, 90772, 90774 and 90775. These pairings all have a modifier indicator of 1 except 69990.

The latest round of CCI edits also targets retinal detachments, bundling 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique) with vitrectomy codes 67041 and 67042.

Reasoning: All of these codes describe a retinal detachment repair. "Code 67108 usually involves external and internal approaches to fix the detachment, whereas 67041-67042 only indicate internal work," Bode says. Because 67108 includes internal work as well as external, you would not also bill 67041-67042 for internal work that is already part of 67108, she adds.

Still more: CCI also bundles retinal detachment code 67112 (Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair[s] using scleral buckling or vitrectomy techniques) with vitrectomy codes 67036 and 67039 with a modifier indicator of 1. These procedures both represent repairing the detachment but using different techniques, so your ophthalmologist likely won't perform both surgeries during the same session, Bode says.

Starting in January, you cannot report new complex retinal detachment code 67113 (Repair of complex retinal detachment [e.g., proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees], with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens) with 36000, 36410, 37202, 62318, 62319, 64400, 64402, 64405, 64415-64417, 64450, 64470, 64475, 66830, 66840, 66850, 66852-66940, 66982-66986, 67005-67025, 67028-67042, 67101-67112, 67141, 67145, 67208-67221, 67227, 67228, 67500, 67515, 69990, 68200, 90760, 90765, 90772, 90774, 90775 and G0186. CCI puts a modifier indicator of 1 on each of these bundles except 69990.

• CCI bundles 68815 (Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent) into new dilation code 68816 (... with transluminal balloon catheter dilation) with a modifier indicator of 1. "These codes use different techniques to resolve the issue of a block (congenital or acquired) in the nasolacrimal duct. You either dilate and fix the problem, or have to place a stent and leave the stent for a period of time (typically six months) to keep the duct open. You wouldn't commonly perform these at the same session," Bode says.

• As of Jan. 1, consider 68816 bundled with 36000, 36410, 37202, 62318, 62319, 64415-64417, 64450, 64470, 64475, 67500, 68810, 68811, 69990, 90760, 90765, 90772, 90774, 90775 -- all with having a modifier indicator of 1 except 69990.