CODING Q & A

Proper Coding for Complex Procedures

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. I have utilized your retina surgery examples to help with coding so I thought of you when this scenario came up. Could you please advise us how to correctly code a surgery for a patient with a tractional detachment and vitreous hemorrhage in the left eye who also has proliferative diabetic retinopathy?

The retina doctor will perform a pars plana vitrectomy, epiretinal membrane dissection, intraocular wet-field cautery, and panretinal photocoagulation. The patient also had prior PRP laser during the global period on both eyes.

Can we consider the vitrectomy with PRP as a more extensive procedure from the PRP laser performed prior to this surgery but during the global period? We have different opinions and would appreciate your insight.

A. This case presents some interesting concepts. The correct CPT codes are 67038 (Pars plana vitrectomy with epiretinal membrane stripping) + 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 bucking, and/or removal of lens by same technique).

The endolaser panretinal photocoagulation (CPT code 67040) is bundled with CPT code 67108.

Regarding the modifiers — this is definitely a good example of the second use of modifier 58 (less extensive to more extensive procedure).

Q. If there are 2 surgeons performing a case, such as an anterior segment surgeon doing the cataract extraction and dropping the nucleus and the retina surgeon coming in and removing the lens and doing a pars plana vitrectomy, should modifier 62 or 79 be used? Do the modifiers have to be used if the surgeons are from the same practice? How about from a different practice?

A. First let's review the 2 modifiers in question.

CPT defines modifier 62 as follows: "62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding the modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons.

Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedures(s) are performed during the same surgical session, separate code(s) may also be reported with the modifier 62 added. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier 80 or modifier 82 added, as appropriate."

This may be a little confusing, but it is generally used when the 2 surgeons are working together on the same primary operation(s) that have the same CPT codes. An example might be a case in which 2 plastic surgeons perform a facial reconstruction after trauma.

Modifier 79 is defined in CPT as follows: "79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79. (For repeat procedures on the same day, see 76.)"

There are other uses for modifier 79 that Medicare allows under special circumstances and one of these is to indicate that 2 surgeons of different subspecialties or training (as of this writing, ophthalmology has not designated subspecialties like internal medicine has done) have performed separate and distinct portions of an operation for which the other surgeon may not be qualified.

In the case described, the proper modifier would be 79 and it should be appended to each surgeon's claim. Two separate claims should be prepared whether or not the surgeons are in the same practice. Technically, the modifier should not be needed if the surgeons are from different practices; however, billers have told me that without the modifier they frequently experience denials.

CPT codes copyright 2006 American Medical Association. RP