Ophthalmology and Optometry Coding Alert

Question: One of our ophthalmic surgeons performed a vitrectomy (67005) for a vitreous prolapse diagnosis and a cataract removal (66984) for pseudoexfoliated lens and nuclear sclerosis diagnoses. I see on the CCI edits that 66984 includes 67005. But if the surgeon made the vitreous prolapse diagnosis prior to surgery, can I report both 66984 and 67005? Do I need a modifier?

Washington Subscriber

Answer: Whether you can report a vitrectomy separately from a cataract surgery procedure depends on whether the vitreous collapse was an iatrogenic (inadvertently introduced) complication. Ophthalmologists often have to perform a vitrectomy during cataract surgery due to vitreous collapse while removing a dense, senile cataract. In those cases, Medicare considers the vitrectomy a component of the cataract surgery, and thus not separately payable.

The Correct Coding Initiative (CCI) bundles vitrectomy codes 67005 (Removal of vitreous, anterior approach [open sky technique or limbal incision]; partial removal) and 67010 (... subtotal removal with mechanical vitrectomy) into cataract surgery codes 66982 and 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique ...).

Exception: If a prolapsed vitreous exists and the surgeon knows about it in advance -- and documented it in the patient medical record -- it is not a complication of the cataract surgery. Therefore, the physician who plans to perform a vitrectomy during the same operative session as a cataract surgery could code separately for the vitrectomy using modifier 59 (Distinct procedural service): 67005-59 or 67010-59.

Key: Documentation and diagnosis codes can get you reimbursement. Use 379.26 (Vitreous prolapse) for the vitrectomy, and the appropriate cataract diagnoses (in this case, 366.11, Pseudoexfoliation of lens capsule, and 366.16, Nuclear sclerosis) for the cataract removal. Remember that you should always code based on documentation, or you could face fraud allegations.

Be prepared to provide documentation showing the ophthalmologist's intent to repair a known vitreous prolapse found prior to surgery in case you receive denials when using these codes together, despite using modifier 59. Payers are aware of the potential for abuse of 59 and may want you to go through the review process to prove you've met the definition of "distinct procedural service."