Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist diagnosed a patient with bilateral proliferative diabetic retinopathy (PDR) with macular edema due to uncontrolled type 2 diabetes and treated it with panretinal photocoagulation (PRP). Which code do I use for the PRP, and should I use one code for the diabetes and another for the ophthalmic manifestations?

Ohio Subscriber

Answer: The physician used a laser on the entire retina to destroy tiny vessels, so you’ll report 67228 (Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation). Had the ophthalmologist treated only one eye, you’d report the laser code once with the appropriate RT (Right side) or LT (Left side) modifier. Since they treated both eyes during one session, report 67228 on one line with modifier 50 (Bilateral procedure). The Medically Unlikely Edits (MUEs) limit 1 unit to be reported per claim. Some non-Medicare payers may allow listing the code on two lines with modifiers RT and LT, but Medicare does not.

Code 67228 has a bilateral status of “1,” meaning that if you report it bilaterally, carriers will reimburse 150 percent of the fee schedule amount for a single code (or your total actual charge for both sides, if it’s lower).

Diagnosis roundup: The E11.3- (Type 2 diabetes mellitus with ophthalmic complications) range of codes specifies type 2 diabetes mellitus, as well as the type and severity of ophthalmic complications. Because the type is specified as PDR, you can exclude the unspecified (E11.31-) codes and those for nonproliferative diabetic retinopathy (E11.32-, E11.33-, E11.34-).

To arrive at the correct code for PDR, consider two things: whether there is macular edema and the eye(s) affected. Since the patient has bilateral macular edema, you’ll use E11.3513 (Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral).

However: Not all ophthalmic manifestations are covered in the E10.3 and E11.3 series. For example, E11.39 (Type 2 diabetes mellitus with other diabetic ophthalmic complication) contains an instruction to “use additional code to identify manifestation, such as diabetic glaucoma (H40-H42).”