Ophthalmology and Optometry Coding Alert

Question: Do retina photocoagulation codes 67210 and 67228 represent bilateral procedures? When our ophthalmologists treat both eyes using photocoagulation during the same session, how should we report the bilateral laser treatment?

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Answer: Neither photocoagulation procedure is designated as bilateral per CPT^®. Although background diabetic retinopathy (BDR) and proliferative diabetic retinopathy (PDR) often occur in both eyes, the treatments for these conditions are inherently unilateral. If the ophthalmologist treats a retinal lesion in only one eye, report laser code 67210 (Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation) once. But when they treat both eyes during one session, report the laser code twice, either on one line with modifier 50 (Bilateral procedure): 67210-50 or two lines with modifiers RT (Right side) and LT (Left side): 67210-RT, 67210-50-LT, depending on payer preference.

Medicare has assigned both 67210 and 67228 (Treatment of extensive or progressive retinopathy … photocoagulation) a bilateral status of “1,” meaning that if you report them bilaterally, payers 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).

For instance, in 2023, Medicare’s national, unadjusted allowed amount for a bilateral PRP performed in an office setting would be $509.33; 150 percent of Medicare’s fee schedule amount for a single 67228 ($339.55).

Tip: To find out if a CPT^® code is bilateral or unilateral, you can check the Medicare Physician Fee Schedule (MPFS). You can find the bilateral indicator in column “Z” (“Bilat Surg”) of the MPFS spreadsheet.

Make sure to mind the global period for repeat photocoagulation. Subsequent treatments of 67210 or 67228 on the same eye within the postoperative period, 90 days and 10 days respectively, are not separately billable.