CODING Q&A

Use the Appropriate Code for Complex Retinal Detachments

ANSWERS PROVIDED BY RIVA LEE ASBELL

This month's column will clarify any confusion regarding the new complex retinal detachment code. In CPT, this code is defined as:

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°), 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).

CONFUSING "COMPLEX" WITH COMPLICATIONS

Foremost, the code is to be used for complex cases and not for cases during which complications occur. Most often, the pre-existing conditions underlie the need for the use of the code and the surgeon will be able to plan prospectively for the coding.

Let's begin with reviewing the CPT definition. First, the types of cases that the code should be used for are described. Second, the procedures that must be performed (vitrectomy and membrane peeling) are given, and lastly, the other techniques that are included in the definition and thus will be bundled are enumerated. In essence, it replaces the old 67038 + 67108 (epiretinal membrane peeling plus repair of retinal detachment etc.) combination.

Prior to the introduction of CPT code 67113 in 2008, most complex retinal detachment repairs were coded using the previously mentioned 67038 + 67108 combination. This paid significantly higher than the new code.

In addition, a mistake occurred when the new code payment levels were issued and 67108 paid higher than 67113. This was quickly resolved.

However, many retina surgeons are unhappy with the current reimbursement, which was given to the procedure when it was evaluated by the RUC (Relative Value Update Committee), the organization that recommends values to Medicare for procedures. As a result, attempts at erroneous creative coding abound.

NCCI BUNDLING ISSUES

The following 2 letters highlight a major issue when coding for complex retinal detachment procedures:

"I recently did a very long case on a diabetic patient who had a tractional and rhegmatogenous retinal detachment with PVR. The case took 6 hours. It involved extensive peeling of membranes and included a panretinal photocoagulation. I billed a 67108 and a 67041. I avoided the 67113 and 67041 because it pays less. Am I doing this correctly?

Another inquiry highlights the confusion often found in attempt to code these procedures.

"I recently did a primary retinal detachment repair (non-complex) using scleral buckle and vitrectomy. Patient also has an ERM, so I peeled it off. Can I do 67108 and 67041 (because it is non-complex retinal detachmnent)?"

These physicians were unaware of the bundles and that payment would only be issued for CP code 67108, which pays less than 67113. Bundles in the NCCI cannot be broken vicariously. CPT code 67113 includes CPT code 67041 (removal of precellular membrane). To break the bundle every time you perform this combination would surely invite an audit. The first inquiry shows that the physician was not aware of the correction and the second erroneously defines complex vs non-complex.

CONCURRENT LENSECTOMY

In the September 2008 column, we addressed the proper lensectomy code to use in conjunction with vitrectomy procedures. The correct choice is CPT code 66850 (Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) of lens material; pars plana approach, with or without vitrectomy). When performing a lensectomy in conjunction with complex retinal detachment repair, you should not code it separately due to the NCCI bundles. Do not break the bundle.

CPT codes copyright American Medical Association. RP