CODING Q&A

Responding to a Potpurri of Complex Surgical Coding Issues

Information Provided By Riva Lee Asbell

This month I'll answer a mixed bag of surgery-related questions.

Q. Is a posterior capsulotomy performed in the ASC with the vitrector billable when performed at the same session as the retinal detachment repair surgery (67108) when a pseudophakic patient has a secondary lens opacification? I have read that the removal of the lens is usually performed because the physician needs to see the back of the eye where the retinal detachment is located. Does this mean then that the capsulotomy is considered part of this procedure (67108), or is it billable in addition to the 67108?

A. This is a difficult question since there is no specific CPT code to describe the procedure when it is performed as part of another procedure except 66820 (Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Zeigler or Wheeler knife)) in CPT, which would not be applicable. A capsuolotomy is considered part of a cataract extraction and as such is included with 67108 (Repair of retinal detachment by vitrectomy, including lensectomy…) and should not be coded independently in this case.

TIP: CPT instructions state, “Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure/service code.”

Q. The anterior segment surgeon dropped the lens into the posterior segment and sent me the patient, who was then aphakic. I performed a pars plana vitrectomy and pars plana lensectomy using the Fragmatome. The anterior segment surgeon attempted to suture a PC IOL, but it fell into the posterior segment. I retrieved the PC IOL from the posterior segment and placed an AC IOL through an anterior approach. All procedures were performed at the same session. (The surgeons were from two different practices).

A. The correct codes would be 67036 (pars plana vitrectomy) + 67121-51-59 (removal of implanted material posterior segment)+ 66850 (lensectomy) + 66985-51-59 (secondary insertion of IOL).

TIP: Modifier 59 is used here to break the National Correct Coding Initiative bundles. This modifier usage has been under OIG scrutiny for some time now and should only be used in carefully selected instances.

Q. A 30-minute surgery under general anesthesia was performed, removing an infected orbital suture with the scleral buckle. Coding?

A. Some of the responses to this question when posted on a listserv included using 67121 (Removal of implanted material, posterior segment; intraocular) with diagnosis 996.69 (Mechanical complication of other specified prosthetic device, implant and graft/Due to other implant and internal device, not elsewhere classified) and 67413 (Orbitotomy without bone flap (frontal or transconjunctival approach)); with removal of foreign body. The most accurate answer is to use the unlisted code 67299 (Unlisted procedure, posterior segment.)

TIP: The sutures used to attach a scleral buckle are not considered orbital; nor was the implant itself removed, so CPT code 67121 is incorrect. Removal of a scleral buckle is coded 67120. An orbitotomy was not performed nor are sutures considered foreign bodies, so CPT code 67413 is not correct either.

Q. Starting this year, I've had trouble getting two OR procedures paid by Medicare:

► Pars Plana Vitrectomy for RD repair in the right eye: 67108 RT

► Laser treatment for retinal tears in the left eye: 67145 59 LT

I've billed this way in the past and Medicare has paid for the both (1/2 fee of course for the laser). I keep getting denials now for the laser. I am using different diagnosis codes for each. Am I using the wrong modifier?

A. You are coding correctly. Your Medicare Contractor may require modifier 51 also. It may be a glitch in their computer processing. It is best to appeal. RP

CPT codes copyrighted 2012 by the American Medical Association.