Coding Q&A

Removal of Implanted Material
from the Posterior Segment

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. What is the coding for IOL removal from the posterior segment? A pars plana vitrectomy was performed and the IOL was grasped and brought into the anterior chamber; then, a limbal incision was made to retrieve the IOL and a secondary IOL inserted.

A. There are 2 CPT codes for removal of implanted material: 65920 (removal of implanted material, anterior segment) and 67121 (removal of implanted material, posterior segment, intraocular.

My preferred coding would be 67121 + 67036-59 (pars plana vitrectomy) + 66985 (insertion of secondary IOL) since a pars plana vitrectomy was necessary and the implant had fallen into the posterior segment. It is necessary to unbundle 67121 and 67036 by using modifier 59.

For an exchange of IOLs performed solely in the anterior chamber with no PPV is involved, appropriate coding would be 66986 (exchange of IOL). This is usually performed by anterior segment surgeons.

Q. A patient comes in to the office and the doctor does a 67110 (pneumatic retinopexy). Several days to several weeks later the patient returns and has either cryotherapy (67101 or 67141) or photocoagulation (67105 or 67145).

Is the procedure performed at the second visit billable? Or is it considered a postop procedure? If billable, what modifier is used to code the return visit procedure? 58, 78, or 79)? Does modifier 58 restart the postop period?

It is my understanding the 78 does not restart the postop so payment is reduced by the portion of the RVUs assigned to the postop period. Is that correct? It is my understanding the 79 restarts the postop so payment is made in full. Is that correct?

A. For Medicare, a global fee has 3 components: preoperative portion (10%), intraoperative portion (70%) and postoperative portion (20%). Major surgeries are identified as those having a global period (do not confuse with global fee) of 90 days, whereas minor surgeries have a global period of 0 or 10 days. Let's confine this discussion to major surgeries.

If a second procedure is performed within the global period of the first, in order to be paid a modifier (58, 78 or 79) must be appended to the subsequent surgery. Each modifier has definitive circumstances for which it is to be used.

Modifier 58 is used in 3 scenarios: (1) when the subsequent procedure is staged (planned prospectively);
(2) when a subsequent therapeutic procedure follows a diagnostic procedure; (3) when the subsequent procedure is more extensive than the original procedure. A new global period starts. The second surgery is paid at 100% of the allowable.

Modifier 78 is used for procedures related to the original procedure, including surgery for complications. A new global period does not start. The second surgery is paid at the intraoperative value (ie, 70% of the allowable). However, use of modifier 78 mandates a return to the OR (defined by Medicare as an OR in a hospital or ASC, endoscopy suite, or separate laser suite). If the procedure is performed in the office setting, it is considered part of the postoperative care and cannot be billed.

Modifier 79 is used when the second surgery is unrelated to the first procedure. A new global period starts. The second surgery is paid at 100%.

So, the cryotherapy or photocoagulation performed during the global period of the pneumatic retinopexy takes modifier 78 because it is related to the original procedure. You will be paid at 70% (intraoperative value). The office visit probably is not allowable because it is part of the postoperative for the original procedure (assuming all procedures are being performed for the same or related condition(s) in the same eye).

If a patient presented with a significantly, separately identifiable condition during the global period, such as complaints of a problem in the other eye, then the office visit could be billed. Modifier 24 would have to be used to show that it is unrelated to the global period and this should be combined with modifier 57 if an additional surgery is scheduled.

CPT codes copyright 2006 American Medical Association. RP