Coding Q&A

Coding Challenges: Dealing With Five Thorny Situations

INFORMATION PROVIDED BY RIVA LEE ASBELL

Correct answers for surgical coding inquiries are given from well-crafted questions. Unfortunately, many questions on listservs are shallow and the answers given are wrong because the complete clinical picture was not given, details of the surgery were not mentioned, or operative notes were not provided. Coding from operative notes is necessary to code correctly and optimize your reimbursement and compliance.

This month's column is devoted to some of those coding challenges.

Q. Has anyone performed Ozurdex implant injections as yet? If so, can you tell me if the doctor needed to put a stitch in the injection site because of the large 20-g needle used for the injection? My doctor is concerned about the needle size and the increased possibility of infection with a larger injection site and is wondering if anyone is stitching the site to avoid possible infection. Also, what CPT code would I use for this suture: 66250? 67250?

A. Suturing of the operative site is always included in the procedure and cannot be billed additionally.

Q. When doing injections (ie, Lucentis or Avastin), do you just use numbing drops prior, or do any of you actually do — and charge for — a subconjunctival injection?

A. Local anesthesia by the surgeon is always included in the procedure and cannot be billed separately.

Q. A patient presents with a dislocated IOL posteriorly and a retinal detachment. Also, he had a dislocated capsular tension ring and vitreous prolapse anteriorly.

Surgery involved pars plana vitrectomy, removal of dislocated PC IOL from the posterior vitreous, removal of dislocated capsular tension ring, insertion of AC IOL, panretinal endolaser, and gas-fluid exchange.

A. The suggested coding for this complicated case is:

1. 67108 (Repair of retinal detachment by vitrectomy, etc.)
2. 67121 (Removal of implanted material posterior segment)-51-59
3. 65920 (Removal of implanted material anterior segment) -51
4. 66985 (Insertion of secondary implant)-51-59

This case is unusual in the use of modifier 59. CPT code 67108 is bundled with 67121 and needs to be unbundled, as do CPT codes 65920 and 66985. CPT code 65920 is usually thought of as an intraocular lens, but in this case refers to the capsular ring.

Q. Patient had scleral laceration without uveal prolapse and intraocular foreign body (glass) that was sticking into the posterior segment (the vitreous). Surgery involved removal of IOFB (with forceps only), repair scleral laceration, and injection of intravitreal antibiotics. No vitrectomy was done or magnets used. How would you code?

A. 1. 65265 (Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction)
2. 65280 (Repair of laceration; cornea and/or sclera, perforating with reposition or resection of uveal tissue) – 51.

Q. My physician did an exchange of IOL during a vitrectomy by a retina specialist. What is the modifier that I use? The patient was also in the global period for an exchange of IOL.

A. Assuming this is the same session the coding is as follows:
Anterior segment surgeon:
66986 (Exchange of intraocular lens) – 78-79
Retina specialist:
67036 (Pars plana vitrectomy) – 79

For the anterior segment surgeon, modifier 78 is used because of the global period from the prior intraocular lens exchange and modifier 79 is used to show a different specialist. The retinal surgeon also uses modifier 79 to indicate a different specialist.

Use of modifier 79 is helpful to get each surgeon paid according to multiple surgery rules (100% of the allowable for the first procedure and 50% of the allowable for the next four procedures). Otherwise, the procedures will be combined and paid accordingly. Use two bills. RP

CPT codes ©2010 American Medical Association.