CODING Q&A

An Inadvertent Injection Raises Thorny Coding and Legal Issues

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. I have an unusual situation. We have a patient who received an inadvertent intraocular injection of a steroid. I am thinking of coding E870.3 and 360.60. Has anyone done this before? What coding do you suggest?

A. This question is complicated and fraught with serious implications, not only for coding but for risk management as well. For dealing with the risk management issues, I would suggest a good healthcare attorney.

For Medicare coding, some serious issues must be addressed. Medicare only pays for services that are medically necessary. If there were no recorded medical problem with that eye that warranted the injection, the service would not be covered.

Q. My doctor did a pars plana vitrectomy, membranectomy, silicone oil, air/fluid exchange, endolaser, indirect laser, repair of corneal wound, and peripheral iridectomy. The diagnosis was proliferative vitreoretinopathy, retinal detachment, branch vein occlusion. This patient had surgery consisting of vitrectomy and scleral buckle in March 2008 for retinal detachment repair and then had cataract surgery in August 2008 after which the retina redetached. How do I code this?

A. Since you are not in the global period of the first surgery, you do not need to apply any of the modifiers for engendering payment during the global period (modifiers 58, 78 and 79). Your retinal procedures are all covered by the complex retinal detachment repair code, CPT code 67113. The other procedures are bundled.

You do not describe whether or not there was a corneal dehiscence or laceration so, assuming there was a dehiscence, that can be coded additionally with CPT code 66250 (Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure). The peripheral iridectomy is bundled with the operative wound repair and cannot be coded additionally.

Q. A patient has a retinal detachment and is scheduled for pars plana vitrectomy. If the doctor performs the vitrectomy and does indirect laser instead of endolaser, what code would you use to bill this — or can you use 67040 even though indirect laser was used instead of endolaser? I have the same question if cryo is used instead of endolaser. How would this be billed if using PPV and cryo instead of PPV and endolaser for retinal detachment?

A. When the primary surgical technique for repair of a retinal detachment is a pars plana vitrectomy, then use CPT code 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without air of gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique). The surgical techniques that are not in the description are included in the NCCI bundles. The only CPT code to be used is 67108.

Q. We had a patient who winters in Florida tell us that the retina doctor she saw in Florida always did her injections on both eyes on the same day. I was wondering if Florida Medicare pays 100% for each injection given, even on same day. Pennsylvania Medicare (Highmark Medicare Services) will only pay 150% for 2 injections performed on the same day. Is this something that is changing in Medicare? Will they start paying 100% for each injection?

A. The patient seems to have simply stated that the injections were done on the same day, not that the practice was paid 100% of the allowable for each side.

The payment rules for multiple procedures on the same day are national rules for Medicare and are not contractor/carrier dependent. Under Medicare's multiple surgery payment rules — and this applies to all procedures performed at the same session — the first procedure is paid at 100% of the allowable; the next 4 are paid at 50% of the allowable. After 5 procedures the claim is individually considered for payment. So, in the above case the practice would have been paid 150% of the allowable. RP

CPT codes copyright 2006 American Medical Association.