Ophthalmology and Optometry Coding Alert

Question: We have a new retina specialist in our office. He did a vitrectomy with membrane peel and endolaser. How should we report this? Can we bill 67038 and 67040 together even though vitrectomy is in both codes?

California Subscriber Answer: You should report both 67038 (Vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping) and 67040 (Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation) for the procedure you described. You-ll use 67038 for the vitrectomy and membrane peel. For laser photocoagulation, you would use 67040.
 
You may need to append modifier 52 (Reduced services) to indicate to the payer that you-re not double-billing for the vitrectomy. Ask your individual payers if they require this modifier.
 
The Correct Coding Initiative (CCI) doesn't bundle 67038 with 67040, so you-re able to report both codes.
 
Modifier help: Ask your insurance carrier if you should append modifier 51 (Multiple procedures) to 67040. Even when -multiple procedure- reductions apply, you usually won't have to append modifier 51. This is because many payers now use software that automatically detects second and subsequent procedures and reimburses them accordingly, thereby making modifier 51 unnecessary. You should ask your individual payers for their guidelines, however. As always, request the payers- instructions in writing because documentation is your best defense if they question your billing methods.