CODING Q&A

Anterior-segment Surgery and Retinal Physician Collaboration

SUZANNE L. CORCORAN, COE • MARY PAT JOHNSON, COMT, CPC, CPMA, COE

Group practice relationships afford physicians a variety of benefits, not the least of which is the expertise of colleagues to assist with specific patients. When anterior-segment surgery does not go as planned, the surgeon sometimes requests a retina specialist’s expertise. Reimbursement in such cases is not as simple as the sum of the parts. To illustrate the relevant Medicare rules and the effect on reimbursement when the anterior-segment surgeon and the retina specialist are both members of the same group practice, we’ll use familiar scenarios.

CASE 1

Your partner, Dr. Waterfall, performed cataract surgery seven days ago. At today’s postoperative visit, the patient complains of increasing blur since day 1. Dr. Waterfall asks you to examine the patient today for possible CME; your exam and concurrent OCT find CME in the operated eye. You advise the patient to use NSAID and steroid drops TID. How are you, the retina specialist, reimbursed?

Medicare’s global surgery package contains the applicable rules (Table 1). The key points are:

• The surgeon’s exam is a postop visit and so is yours because you are both members of the same group practice addressing a complication following cataract surgery. No separate charge for either exam is warranted as Medicare has already reimbursed the practice for postop care within the global surgery package for cataract surgery.

• The OCT you did to assess the complication is not part of the global surgery package. Separate reimbursement is warranted.

CASE 2

The patient in case 1 returns after one week with no improvement in vision. Dr. Waterfall again asks you to see the patient. After your exam, you recommend an intravitreal injection of nonpreserved triamcinolone acetonide; the patient consents to the treatment. How are you, the retina specialist, reimbursed?

Again, refer to the concept of a global surgery package (Table 1). The key points are:

• Your eye exam that identified a surgical complication is part of postop care as explained in case 1.

• Part B Medicare does provide coverage for medications that cannot be self-administered, such as intravitreal medications, subject to the global surgery rules. While your procedure to administer the triamcinolone acetonide (CPT 67028) is included in the global surgery package, because it is surgical service during the postoperative period to treat a complication not requiring a return to the operating room, Medicare excludes the supply of injectable medication (J3300) from the global surgery package. It is separately reimbursed.

CASE 3

Your partner, Dr. Waterfall, performed cataract surgery on a patient yesterday. On exam today, a small tear is noted in the posterior capsule behind the IOL and a tiny fragment of cortical lens material is seen in the anterior vitreous. Waterfall again asks you to see the patient. After your exam, you recommend pars plana removal of the cataract fragment (CPT 66852). The patient consents to the treatment and you schedule surgery for the following morning. How are you, the retina specialist, reimbursed?

Again, refer to the concept of a global surgery package (Table 1). The key points are:

• Your eye exam that identified a surgical complication is part of postop care as explained in case 1.

• A return to the OR during the postoperative period to perform surgery to address a complication of the earlier procedure is separately reimbursed whether performed by you or the original surgeon in your group. Because payment is made to the group, both ophthalmologists can be figuratively considered as “the same physician.”

• A claim for reimbursement for subsequent surgery during the postoperative period requires an appropriate modifier (Table 2). For case 3, modifier -58 applies. While modifier -78 is an alternative choice for a related procedure, we note that CPT 66852 is assigned 25.03 RVUs while 66984 has only 18.79 RVUs; consequently modifier -58 is more accurate because 66852 is more extensive than 66984.

CASE 4

Your partner, Dr. Waterfall, calls you from the OR where he is performing cataract surgery and describes a complication involving a dropped nucleus. You join him in the OR a few minutes later to perform a core vitrectomy (CPT 67036) followed by removal of the nucleus with fragmentation (CPT 66850). Dr. Waterfall finished the case by sewing in an IOL, which is a hallmark of complex cataract surgery (CPT 66982). How are you, the retina specialist, reimbursed?

For reimbursement purposes, you can think of the two ophthalmic surgeons from the same group practice as a single super surgeon rather than two different surgeons. This is because remittance is not made to either doctor — instead, it is made to the practice when physicians reassign benefits to their employer.¹ A single claim, not two, is required for reimbursement. Of the CPT codes mentioned above, 66850 is bundled with 66982 by the NCCI edits and should not be entered on the claim form; only 67036 and 66982 will appear on the CMS-1500.² The bigger procedure, in terms of RVUs, is 67036, which will be paid at 100% of the allowed amount, and the smaller procedure will be paid at 50% of the allowed amount. No modifiers are required.

It is important to note that the concept of cosurgeons (modifier -62) does not apply in this situation because you and Dr. Waterfall are both ophthalmologists. Modifier -62 is used to identify cosurgeons of different specialties working together simultaneously.³

MUTUAL BENEFIT IS POSSIBLE

After reading these cases, readers should not infer that Dr. Waterfall has benefited economically at the expense of his partner, the retina specialist. Physician compensation is not necessarily fixed by reimbursement but is a matter of employment contracts. It’s plausible and desirable to create a mechanism to pay both ophthalmologists for collaborating in the care of the patient that is independent of claims processing. Patient care should not suffer or be delayed due to physician financial self-interest.

All of these cases illustrate how reimbursement is affected within a group practice. The answers are very different when the anterior-segment surgeon and the retina specialist are not part of the same practice. Of course, easy collaboration between ophthalmologists is hindered by any separation, which is a significant consideration. RP

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