CODING Q&A

Coding for a Recurrent Retinal Detachment

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. A patient had pars plana vitrectomy, air-fluid exchange, and injection of silicone oil for total retinal detachment. Within the global period, the patient had cryotherapy and scleral buckling for recurrent detachment.

The doctor codes 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. Could we bill 67107 instead? I don't completely understand when to use code 67112. In this case, a vitrectomy (plus) was done at the initial surgery, and a scleral buckling (plus) was done at the second surgery. Reimbursement is better for 67107 and makes more sense to me.

A. First, some background. Years ago, many insurers did not recognize modifiers, and when the same CPT code(s) was used for repair of a recurrent retinal detachment, the claim was often rejected as a duplicate charge. To circumvent this problem, CPT code 67112 was developed. This was not a problem for Medicare because the modifiers were used to process payment.

With the advent of HIPAA, all insurers are supposed to recognize modifiers and claims processing is supposed to be streamlined. There are still some insurers that are not processing claims with modifier application. The answer depends on who the insurer is, what procedures were performed, and what the reimbursement for the procedures is. The following information pertains to Medicare only:

As an example, the following 2008 reimbursements are found in Empire New Jersey Area 01 for the following 4 CPT codes.

67112 (recurrent retinal detachment repair) $1215.62

67107 (retinal detachment repair/scleral buckle) $1113.87

67108 (retinal detachment repair vitrectomy etc) $1475.69

67113 (complex retinal detachment repair) $1572.68

You are free to select the code that most accurately describes the procedure performed. In the global period, either modifier 58 or 78 will be chosen depending on the case scenario. If there is progression of the disease process and the procedure is more extensive, CPT code 67113 most likely will be used along with modifier 58. If there is a repeat of the original procedure or a lesser procedure (compared to the original), the same or lesser CPT code would be used with modifier 78.

Think of a food-chain analogy. If you are going up the food chain to a more complex procedure, use modifier 58. If you are going down the food chain or staying in the same place, use modifier 78.

Using the example given in the question, the appropriate and financially advantageous coding would be CPT code 67112 with modifier 78.

Q. My doctor has told me that when using 67229 for retinopathy of prematurity on both eyes during the same session, we are now allowed to bill separately using RT and LT and should get paid 100% for each eye. Any insight would be appreciated!

A. CMS issues a complex database document — the Medicare Physician Fee Schedule Database — that contains a wealth of information that sometimes may be daunting and confusing. In this document, each CPT procedure code has a multiple surgery indicator that tells the contractor how to pay claims when 2 or more surgeries are performed at the same session by the same physician. CPT code 67229 carries an indicator of 2 which means that the first procedure is paid at 100% of the allowable and the next 4 procedures are paid at 50% of the allowable.

Thus, the information you received was incorrect and when both eyes are treated, the payment is at 150% of the allowable. The database may be found under: http://www.cms.hhs.gov/PhysicianFeeSched/01_Overview.asp#TopOfPage and then go to PFS (Physician Fee Schedule) Relative Value Files.

CPT codes copyright 2006 American Medical Association. RP