Ophthalmology and Optometry Coding Alert

Question: After discussing the risks and benefits of both cryotherapy and photocoagulation for a retinal detachment repair with the ophthalmologist, the patient preferred photocoagulation. But the ophthalmologist had to discontinue due to the patient’s inability to tolerate the procedure and performed cryotherapy instead. Should I code 67105-53 as well as 67101?

Kentucky Subscriber

Answer: Code only the procedure the ophthalmologist finished (67101, Repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy, with or without drainage of subretinal fluid), not the one he abandoned (67105, ... photocoagulation, with or without drainage of subretinal fluid). Appending modifier 53 (Discontinued procedure) would not be appropriate in this case.

Reason: Chapter 12, Section 30 of the Medicare Claims Processing Manual explains, “An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach. There may be separate CPT® codes describing each service. ... These procedures are considered ‘sequential procedures.’ Only the CPT® code for one of the services, generally the more invasive service, should be billed.”

Opportunity: Your ophthalmologist, however, may be able to append modifier 22 (Unusual procedural services) to the completed procedure to indicate the additional work performed in converting from one procedure to another. The additional work must be significant and documented in the procedure note.