A Look at the New Vitreoretinal Surgical Codes

Revolutionary changes have taken place.

RIVA LEE ASBELL

The CPT changes for retina/vitreous surgical coding are the most significant in years. The old standby combination of 67038 and 67108 for coding complex retinal detachment surgery with vitrectomy for retinal detachment with proliferative vitreoretinopathy has been changed because CPT code 67038 has been deleted. You will have to study this carefully and change the way you have been coding your vitreoretinal surgeries. This applies to physician coding as well as ambulatory surgery center (ASC) facility coding.

THE CODES

The new vitrectomy codes are subsets of CPT code 67036. As noted above, CPT code 67038 has been deleted. Here they are:

67036: Vitrectomy, mechanical, pars plana approach;

—67039: with focal endolaser photocoagulation

—67040: with endolaser panretinal photocoagulation

—67041: with removal of preretinal cellular membrane (eg, macular pucker)

—67042: with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas, or silicone oil)

—67043: with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas, or silicone oil) and laser photocoagulation.

In addition, you should now use 67113 for the cases you formerly coded with the combination 67038 + 67108.

67113: Repair of complex retinal detachment (eg, 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.

There also is a new code (67229) for the treatment of progressive retinopathy in preterm infants, and clarification of "1 or more sessions."

67229: Treatment of extensive or progressive retinopathy, 1 or more sessions, (eg, diabetic retinopathy), photocoagulation preterm infant (less than 37 weeks gestation at birth), performed from birth to 1 year (eg, retinopathy of prematurity), photocoagulation, or cryotherapy

The clarification of "1 or more sessions" is provided in the following instruction: "Codes 67141, 67145, 67208-67220, 67227, 67228, 67229 include treatment at 1 or more sessions that may occur at different encounters. These codes should be reported once during a defined treatment period."

NATIONAL CORRECT CODING INITIATIVE (NCCI)

It is imperative to review the code pair edits for the new codes since changes are in place and your billing staff may not be familiar with them.

ASC CODING

This is the first year of the 4-year transition program for ASC payment reform. It is very different from the old system, which was essentially one of pigeonholes. If you were given a CPT code, you matched it to one of 9 categories and that was that.

In the new system, it is imperative that a coder has mastery of surgical coding — particularly for the more complicated cases. All codes must be captured and placed in proper order. Modifiers, as always, control payment for Medicare. Thus, it behooves the physician to be sure to code all surgeries and be cognizant of the new codes. Many ASCs do not have surgical coders, and even those that do will need new training.

Many ASCs are attempting to bring in vitreoretinal procedures as a new source of revenue, given the new payment system. Many retina surgeons are being invited to participate in ownership. Surgeons should seek expert consultation and evaluation before they make this decision.

Another decision that needs to be made is whether or not to bring office-based procedures, such as intravitreal injections, into the ASC. Carefully analyze your financial situation before making this switch. Both the ASC and the physician will receive less reimbursement for performing procedures in an ASC that were traditionally office-based. Make the right financial decision rather than only taking convenience into consideration.

Make sure your billing staff learns the new modifiers and usages proscribed by Medicare for ASC billing. Modifier 52 has a different use in ASC coding and applies to radiology services only. Modifier 50 is not to be used for bilateral procedures. You can use either units "2" or a 2-line entry in lieu of modifier 50 or a 2-line entry. Use of modifier 50 will result in your claim being paid as if both procedures were performed only once.

CLINICAL EXAMPLES

Here are some examples of clinical scenarios and the proper CPT coding for 2008.

Case 1. Patient had recurrent tractional retinal detachment in the right eye with vitreous membrane formation. This occurred within the global period. Current surgery consists of rerepair of retinal detachment by vitrectomy, removal of membranes, placement of silicone oil, fluid-gas exchange, and peripheral iridectomy. Code all procedures.

Diagnosis:
1) 361.81 Traction retinal detachment with vitreoretinal organization
2) V45.69 Previous retinal detachment surgery

Surgery:
Diagnosis: 1) 1, 2
Procedures: 67113: repair of complex retinal detachment
Modifiers: -58-RT
Diagnosis: 2) 1
Procedures: 66625: peripheral iridectomy
Modifiers: -51-79-RT

TIP: Modifier 58 is used because you are going from a lesser to a greater procedure in the global period due to disease progression. The 79 modifier is used because that procedure is unrelated to the earlier surgery.

Case 2. Patient presented with a macular hole and macular degeneration. Surgery was performed consisting of a total pars plana vitrectomy, stripping of the internal limiting membrane using indocyanine green and fluid-air exchange. Code all procedures.

Diagnosis:
1) 362.54 Macular hole, right eye

Surgery:
Diagnosis: 1) 1, 2
Procedures: 67042: vitrectomy with repair of macular hole and stripping of internal limiting membrane
Modifiers: -RT

Case 3. Patient presented with choroidal neovascularization, which was treated with intravitreal bevacizumab. After treatment, scar tissue developed under the fovea, and the patient's vision worsened. During surgery, a macular hole was found. Surgery consisted of pars plana vitrectomy with injection of subretinal balanced salt solution, removal of subretinal neovascular membranes, internal limiting membrane peeling, and injection of C3F8 gas. Code all procedures.

Diagnosis:
1) 362.16 Choroidal neovascularization, right eye
2) 362.56 Macular hole, right eye
3) V45.69 Previous retinal procedure

Surgery:
Diagnosis: 1) 1
Procedures: 67043: pars plana vitrectomy with removal of subretinal neovascular membrane
Modifiers: -RT
Diagnosis: 2) 2
Procedures: 67042: pars plana vitrectomy with stripping of internal limiting membrane
Modifiers: -51- RP