Outpatient Facility Coding Alert

Retinal Reimbursement:

Understand the Procedures Involved for a Fair Claim

Published on Mon Jul 20, 2015

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Read on to know the common retinal coding pitfalls.

Retinal detachments are generally an emergency situation. The way to get rightly reimbursed lies in knowing the procedures and how to handle recurrent and complex repairs.

Here’s a look at common ways of dealing with detached retinas, and common errors to watch out for.

Bill Once for Cryotherapy or Diathermy

If your physician uses cryotherapy or diathermy to repair the detachment, you’ll submit CPT® code 67101 (Repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy, with or without drainage of subretinal fluid).

Procedure: The ophthalmologist uses a probe to seal the detached or torn portion of the retina against the wall of the eye, using either cold (cryotherapy) or heat (diathermy). This is usually performed in the anterior (front) portion of the eye, where lasers cannot be used. This is considered a “non-surgical” procedure.

Watch for: As the code description says, you would report this code once for one or more sessions of repair.

“The treatment period is usually defined by the physician and may vary as to length of treatment depending on the patient’s diagnosis and the area being treated,” notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “During the defined treatment period, it is not appropriate to bill for each session and the CPT® code should be billed only once.”

If, once the treatment period has ended, the patient requires re-treatment several months later due to progression of the disease, then a new treatment period would be defined and the CPT® code may be billed again, Mac says.

Don’t miss: Documentation must be present in the medical record by the provider to define what he believes will be the “treatment period” for the condition, advises Mac.

Know Photocoagulation Plan Might Change

For photocoagulation coding, you turn to 67105 (Repair of retinal detachment, 1 or more sessions; photocoagulation, with or without drainage of subretinal fluid).

Procedure: The ophthalmologist places a contact lens on the patient’s eye and passes a laser beam through the dilated pupil above the site of the retinal detachment to seal the torn area of the retina. The pigments of the tissues in the area of the tear absorb the laser light and convert it to heat that helps to seal the edges of the detached retina. If subretinal fluid needs to be drained, the provider makes an incision in the sclera to drain the fluid.

Watch for: As with code 67101, you would report 67105 for one or more sessions of repair.

Discontinued procedure: If the ophthalmologist starts with photocoagulation but abandons it later in favor of cryotherapy or diathermy due to the patient’s inability to tolerate it and performs cryotherapy instead, don’t report the abandoned procedure as 67105. Instead, report only the procedure the ophthalmologist finished: 67101. However, for professional services billing, you can append modifier 22 (Increased procedural services) to the completed procedure to indicate the additional work performed in converting from one procedure to another. The additional work must be significant and documented in the procedure note.

Check for the Scleral Buckling Procedure

More extensive retinal repairs might involve CPT® code 67107 (Repair of retinal detachment; scleral buckling [such as lamellar scleral dissection, imbrication or encircling procedure], with or without implant, with or without cryotherapy, photocoagulation, and drainage of subretinal fluid).

Procedure: To seal the torn area of the retina, the ophthalmologist may perform cryotherapy (as described in code 67101) or photocoagulation (as described in code 67105). He then sutures a scleral buckle by cutting a groove in the sclera (lamellar scleral dissection), or attaching a silicone band to the sclera and placing a sponge under it. This pushes the hole or tears against the outer scleral wall, creating a support for the re-attached retina. If necessary, the ophthalmologist drains subretinal fluid through an incision in the sclera. You normally will report only 67107, though there might be times when you’re justified in submitting 67107 with either 67101 or 67105. Ensure you have clear documentation supporting that they were separate procedures, and append a modifier to break the CCI edit that bundles the codes.

Watch for: If the ophthalmologist also removes some of the vitreous, you may be tempted to report a separate vitrectomy code. Instead, you should consider code 67108 (see below).

Gel Drainage Means Vitrectomy

CPT® code: 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique).

Procedure: In tandem with other repair techniques such as cryotherapy or photocoagulation, the ophthalmologist might drain some of the vitreous gel from the inside of the eye, to provide better access to the repair. He then injects a gas bubble or silicon oil into the vitreous cavity to help hold the retina in place.

Watch for: Unlike with a gas bubble, the body cannot absorb silicon oil back into the body, so if the ophthalmologist inserted silicon oil into the vitreous cavity, he must remove it later. If your ophthalmologist removed the silicon oil by performing a vitrectomy, which is how it’s typically done, report code 67036 (Vitrectomy, mechanical, pars plana approach). Depending on the circumstances and documentation, you may need to use modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) if the removal procedure was planned at the time of the initial vitrectomy procedure in which the silicon oil was inserted.

Know if Physician Performs Pneumatic Retinopexy

Sometimes the surgeon injects air to help while performing the repair. If so, the correct CPT® code is 67110 (Repair of retinal detachment; by injection of air or other gas [e.g., pneumatic retinopexy]).

Procedure: The ophthalmologist injects a gas bubble into the vitreous cavity to hold the retina in place, in combination with cryotherapy or photocoagulation to repair the detachment.

Watch for: If the ophthalmologist performs a vitrectomy along with the injection of air, you would report only code 67108 (see above). The descriptor includes “with or without air or gas tamponade,” so you would not also include 67110.

Submit 67112 for Recurrent Repair

CPT® code 67112 (Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair[s] using scleral buckling or vitrectomy techniques) applies if a second repair is needed.

Procedure: If a previous scleral buckling (67107) or vitrectomy (67108) has failed, the ophthalmologist repeats the repair.

“It is not uncommon to have a recurrence of a retinal detachment treated previously with an ipsilateral detachment repair via scleral buckling or vitrectomy,” notes Mac. “You should use this specific code for re-treatment if applicable when re-treatment involves scleral buckling or vitrectomy methods.”

Rely on 67113 for Complex Retinal Detachments

The most extensive retinal repair code is 67113 (Repair of complex retinal detachment [e.g., proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees], with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens).

Procedure: The ophthalmologist performs a repair with vitrectomy as described in 67108, but also performs epiretinal membrane stripping – the peeling away of a growth of membrane across the macula.

Watch for: Do not be tempted to report code 67113 just because a procedure is difficult or has complications, says Mac. The code is roughly analogous to complex cataract surgery code 66982 (Extracapsular cataract removal…) in that the complexity of the surgery must be planned prospectively.

Proliferative vitreoretinopathy (PVR) is the presence of preretinal or subretinal membranes. Grade C is further recognized as being anterior to the equator (grade Ca) or posterior to the equator (grade Cp) and the number of clock hours involved (1 to 12).

Code 67113 includes vitrectomy with epiretinal membrane peeling, which can make this a more complex procedure, Mac says.

Other complications listed in the descriptor for 67113 include:

Patient is diabetic with ophthalmic manifestations.

Retinopathy of prematurity – abnormal blood vessel development in the retina of a premature infant.

Retinal tear is greater than 90 degrees.

Prepare to Change Diagnosis Codes

If you code for any physicians who specialize in retinal surgeries, you’ve probably gotten used to the ICD-9 diagnostic code series 361.xx (Retinal detachment and defects) series. However, starting Oct. 1, 2015, as ICD-10 takes effect, you will need to be familiar with the H33.--- series, which greatly expands on ICD-9 by adding specificity as to which eye is affected.

Example: For a recent partial retinal detachment with a single defect, under ICD-9 you would have only one code choice, regardless of which eye was affected: 361.01 (Recent retinal detach partial with single defect). Under ICD-10, you will be able to choose from: