Ophthalmology and Optometry Coding Alert

Question: The ophthalmologist incised a patient’s conjunctival cyst (68020). One week later, the patient came back with the same problem, and the ophthalmologist excised the cyst. Can I report the excision with a modifier, or does the fact that it’s a related procedure within the postoperative period of the first procedure forbid it?

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Answer: The fact that the excision — 68110 (Excision of lesion, conjunctiva; up to 1 cm) or 68115 (... over 1 cm) — is a more extensive procedure than the incision the ophthalmologist performed earlier (68020, Incision of conjunctiva, drainage of cyst) allows you to report 68110 or 68115 with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).

Key: Even though the ophthalmologist may not have planned or staged the excision at the time of the incision, CPT’s explanation of modifier 58 allows for physicians to use it to indicate that the modified procedure is “more extensive than the original procedure.”

If the ophthalmologist had to perform the excision in the operating room, append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to 68110 or 68115.