Ophthalmology and Optometry Coding Alert

An S code beats an unlisted-procedure code for reporting corneal laser surgery

Look all you want, but you won't find a code for phototherapeutic keratectomy in the CPT book. Coders have two options to correctly report this procedure.

Doctors use the PTK corneal laser to remove layers of corneal clouding or corneal scars, or treat recurrent corneal erosions. Medicare won't pay for it - they consider the correction of vision cosmetic - but other payers might.

Option 1: Report CPT code 66999 (Unlisted procedure, anterior segment of eye). If you do use 66999, it's important to include the right documentation. Keep it simple, says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. Submit a quick cover letter - without the "Dear So-and-so" - noting the patient's name, the date of service, any pertinent demographic information, and two to three sentences indicating the service represented by the unlisted-procedure code.

"That's all you need," she says, "because you have to send the op report along," which should contain all of the remaining information the payer might need. "Submitting unlisted procedures is fairly common right now, so the insurance companies aren't taken by surprise when you send this stuff in. And the payment is not significantly slowed down."

Note: According to Callaway, when you submit an unlisted-procedure code claim for something as identifiable as PTK, 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.

Option 2: A better choice would be HCPCS code S0812 (Phototherapeutic keratectomy [PTK]).

"[S0812] really makes life a lot easier," Callaway says. "With an S code, you have a standardized descriptor, and the carrier has a standardized payment policy on that code." The S codes, according to the HCPCS manual, are used "to report drugs, services and supplies for which there are no national codes but for which codes are needed by the private sector." HIPAA directs insurers to recognize S codes before unlisted-procedure codes, Callaway says.

Problem: Some payers might not accept and reimburse for a HCPCS code, and prefer that you report 66999 with proper documentation. "It depends on the payer," says Brian Swope, CPC, coder/abstracter for the Penn State Milton S. Hershey Medical Center in Hershey, Pa. "Some people will pay with the HCPCS code, and some don't recognize it." Swope recommends checking with the payer to see if it will reimburse for PTK and which code it prefers.

Similar Isn't Good Enough

Although you can compare PTK to a corneal excision procedure, resist the temptation to use 65400 (Excision of lesion, cornea [keratectomy, lamellar, partial], except pterygium), Swope says. "65400 isn't descriptive enough," he says. "I don't think [PTK] fits the description there at all."