Ophthalmology and Optometry Coding Alert

Question: A 67-year-old man presents with macular degeneration. A physician performs OPT on both of the patient's eyes during a single session. How should this be coded?

North Carolina Subscriber

Answer: Ocular photodynamic therapy (OPT), a noninvasive treatment for age-related macular degeneration, is a procedure that relies on the ability of a photoactive drug (Verteporfin), activated by laser light, to destroy the cells the laser light has targeted. OPT is described by code 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]).
 
Typically, when a procedure is performed on both eyes, we term that as a "bilateral" procedure and use the bilateral modifier -50 for billing (67221-50).
 
This is not true for OPT, because there is a specific "add-on" code to describe performing the procedure on the second eye on the same day, +67225 (... photo-dynamic therapy, second eye, at single session [list separately in addition to code for primary eye treatment]).
 
According to CPT, as an "add-on" procedure, the procedure described by code 67225 is always performed in addition to the primary service of 67221 and must never be reported as a stand-alone code. The service (67225) is also exempt from the multiple-procedure concept and modifier -51 (Multiple procedures). 
 
Modifier -51 is used to report a multiple procedure and in the Medicare program results in a reduction of 50 percent of the fee schedule amount for procedures reported in the 2-4 position on the claim form. 
 
As an add-on service, the procedure has already been valued as a multiple procedure and does not require additional designation with modifier -51, which could result in a further reduction.
 
Correct billing when OPT is performed on both eyes on the same day is 67221 (-RT or -LT), 67225
(-RT or -LT). 
 
Note: Remember that at this time only the diagnosis of 362.52 (Exudative senile macular degeneration) is considered medically necessary in the Medicare program, and fluorescein angiography documenting the patient's condition should be kept and maintained in the patient's file.