CODING Q&A

Cataract Combined With Vitreoretinal Surgery

INFORMATION PROVIDED BY RIVA LEE ASBELL

Listservs are replete with questions regarding the surgical coding for various types of cataract and vitreoretinal procedures. This month we are going to address a few of these more difficult cases.

Q. I did a case in which the diagnosis was cataract and macular hole. During the phaco portion, the patient had a zonular dialysis, so I switched to a pars plana lensectomy with fragmatome. I proceeded to do a PPV with ILM peel for macular hole, and finished with AC IOL placement. For this case, I coded:

(1) PPV with ILM peel (67042)
(2) Removal of lens phacofragmentation technique (66850)
(3) Insertion of secondary implant (66985)

A. You did right. Codes 66850 and 66985 are bundled. Since the entire operation was performed in the same session, it might be easier to just use CPT codes 67042 and 66984 (Cataract removal with insertion of IOL).

ISSUE: CPT Code 66850 (Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification) versus CPT code 66852 (Removal of lens material; pars plana approach, with or without vitrectomy)

CPT code 66850 should be used when a lensectomy is performed in conjunction with a vitrectomy procedure, based on CPT instructions. It seems a bit bizarre to retinal surgeons, since an anterior approach is used for this procedure and most retinal surgeons want to use CPT code 66852. That code was developed for primary cataract extraction using a pars plana approach wherein incidental vitreous may be removed, but a core or complete vitrectomy is not performed.

TIPS:

► Use 66850 for phacoemulsification procedures done in conjunction with vitrectomies when an IOL is not being placed.

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Use 66984 (Phaco with IOL) or 66982 (Phaco with IOL, complex) when an IOL is inserted in conjunction with a vitrectomy procedure. You will have to append modifier 59 to get paid for the cataract and IOL insertion when performed in conjunction with retinal detachment repair.

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ASCs will not be paid for the use of the phaco machine and the IOL, etc., unless modifier 59 is used.

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Vitrectomies coded with 66852 will result in denials of the code since it is bundled with the vitrectomy codes.

Q. The patient presented with a dislocated IOL posteriorly and a retinal detachment. Also, she had a dislocated capsular tension ring and vitreous prolapse anteriorly.

Surgery involved PPV, removal of dislocated PCIOL, removal of dislocated CTR, insertion of ACIOL, panretinal endolaser, and gas-fluid exchange (for retinal reattachment).

A. Code the case thusly:

67108 (Repair of Retinal Detachment by vitrectomy etc), plus…

67121-59 (Removal of implanted material, posterior segment, plus…

65920 (Removal of implanted material anterior segment), plus…

66985-59 (Insertion of secondary intraocular lens)

ISSUE: In order to be fairly coded and also facilitate ASC coding, modifier 59 has been used in the complicated cases presented in this column. The National Correct Coding Initiative (NCCI) allows certain bundles to be broken to facilitate correct coding; however, its position is that the basic use occurs when the same procedure is performed on the contralateral side.

Do not use this modifier just because you do not agree with the bundle. Make sure your billing staff knows they are not to append 59 merely to engender payment.

TIPS:

► CPT code 67121 was actually developed for removal of an IOL dislocated into the posterior segment.

► Do not break NCCI bundles by using modifier 59 injudiciously. This has been under ongoing investigation by the Office of the Inspector General and I am aware of gross misuse of this application. Ordinarily, it should not be used for ipsilateral procedures. RP

CPT codes ©2010 American Medical Association.

Riva Lee Asbell can be contacted at www.rivaleeasbell.com, where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.