CODING Q & A

Knowing When to Bundle is Key to Good Coding

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. The physician performed a pars plana vitrectomy with epiretinal membrane stripping, air/fluid exchange, and gas injection along with a radial optic neurotomy. I don't know how to code the neurotomy and was told that 67570 is the correct code for the neurotomy.

A. The correct Medicare coding for this case would be CPT code 67038. The air/fluid exchange and gas injection are bundled into the code. As far as the optic neurotomy is concerned, it is not billed using code 67570 (Optic nerve decompression, (eg, incision or fenestration of optic nerve sheath). This is a completely different procedure performed for different diagnoses. I would simply code this entire case as CPT code 67038 (Pars plana vitrectomy with epiretinal membrane stripping).

Q. Could you please review the basic requirements for chart documentation for extended ophthalmoscopy? I keep hearing that it is a very heavily audited code. Our 3-person retinal practice uses it a lot. Thanks.

A. Extended ophthalmoscopy is a designated as a unilateral test, meaning that the provider is paid separately for each eye. Therefore, there must be medical necessity for each eye, ie, signs and symptoms attributable to that eye. Good medicine does not equate to medical necessity for Medicare; thus performing bilateral testing when there is a unilateral problem to ascertain that the other eye does not exhibit any problems should not be billed and should not be reimbursed. A separate interpretation and report is necessary. This is a written narrative report — not a labeled drawing.

The drawing should be anatomically specific to that patient. The drawing should not be able to be considered a sketch. A detailed drawing, preferably with some colors, clearly labeled, and of sufficient size (usually 3-4 inches in diameter) is required. Some years ago, a group of Medicare carrier Medical Directors reviewed extended ophthalmoscopy drawings and the consensus was that these drawings did not differ from what they would expect to see in any nonophthalmic condition where a sketch was made.

Be sure to check your Medicare carrier's LCD (Local Coverage Determination) and Coding Guidelines for this test. If there isn't one, try following Empire New Jersey (www.empiremedicare.com).

Q. How would I get paid when performing a retinal detachment repair in 1 eye and prophylactic laser treatment with an indirect laser in the other eye at the same session? I know the codes are bundled and I am afraid that just using RT and LT modifiers is not enough. How would the procedures be paid?

A. You are correct in being cautious about billing these 2 procedures together; however, you can be paid for both by proper use of the modifiers.

Let's say you perform a retinal detachment repair with vitrectomy etc. on the right eye (CPT code 67108) and at the same session perform prophylactic repair of retinal break using photocoagulation (CPT code 67145) on the left eye. In order to be paid for both procedures, I suggest you append modifier 59 in addition to the RT/LT modifiers showing that it is a different site and also breaking the bundle. Many billers are quite fearful of using modifier 59 — and this should not be.

Each bundle in the National Correct Coding Initiative has a modifier-indicator that informs you whether or not the code-edit pair bundle can be broken. A modifier-indicator of 1 indicates that the bundle may be broken at the discretion of the physician.

A word of caution — do not break bundles simply because the physician does not agree with the bundle or to maximize reimbursement. Use of modifier 59 has been under OIG investigation. Nevertheless, when it is applicable, such as in this case, you should use it.

Medicare payment for cases performed in the same session follows multiple-surgery payment rules. In order of descending payment, you will receive 100% of the allowable of the first procedure and then 50% of the allowable of the next 4 procedures. More than 5 procedures will go to individual claim review.

CPT codes copyright 2006 American Medical Association. RP