Ophthalmology and Optometry Coding Alert

Answer: Though it would seem that the two codes would be considered a bundle (two services that cannot be billed together on the same day), in the Medicare program, they are not. Code 66852 describes the removal of lens material with or without vitrectomy, while 67038 is a vitrectomy with epiretinal membrane stripping. When both procedures are performed in the same surgical session, you should bill both procedures, listing 67038 as he primary procedure with the eye modifier (-LT or -RT), and 66852 with the -51 modifier (multiple procedures) and then the eye modifier.

With the Health Care Financing Administrations (HCFA) payment rule of a 50-percent reduction for multiple procedures, they will realize that you are not billing and getting paid for the full vitrectomy portion of the procedure twice.

Rather, they consider that the reduction of 50 percent that is inherent when billing for the second procedure adequately reduces the service, while still reimbursing the physician for the portion of the service that is not described in both procedures, such as the removal of lens material or epiretinal membrane stripping.

Remember to list the service that has the greater reimbursement first that would be 67038. Then use modifier -51 on the lesser-paying code, which is 66852. Use caution when billing insurance companies other than Medicare private payers may have code bundles that differ from Medicares.