When it comes to coding, an understanding and application of 2 important principles will result in successful reimbursement for retina procedures. Understanding that not all payers follow the same guidelines will help prevent denials and protect revenue by not applying 1 set of coding and billing rules to each individual payer.

The number 1 rule of coding and reimbursement is to identify the payer. Why? Because each unique payer has its own rules and requirements. The second rule is closely linked to the first: do not apply one payer’s rules, or perceived rules, to other payers. All other coding principles hinge on these 2 foundational rules. The first question of coding and reimbursement therefore should always be, “Who is the payer?” This leads to the second question, “What are their requirements?”

In addition to these top rules of coding, this article also presents an overview of 2 other fundamental coding principles: Correct Coding Initiative (CCI) edits and global periods.

FREQUENTLY REVIEW PAYER POLICIES

Medicare Administrative Contractors (MACs) publish local coverage determinations (LCDs) and local coverage articles, and the Centers for Medicare and Medicaid Services publishes national coverage determinations, to provide policies and guidelines for correct coding principles for specific procedures. These policies designate medical necessity, approved diagnosis codes, diagnostic testing requirements, and frequency edits as applicable. Commercial payers may also publish their own policies for procedures. These are often posted on their websites or included in provider manuals. LCDs may vary by region, and they are revised periodically. To review and maintain a current copy of published LCDs for each MAC, visit aao.org/lcds .

A quick example that every retina practice will be familiar with is found in Table 1. The required health common procedure coding system, or HCPCS code, for bevacizumab (Avastin; Genentech) varies by MAC. To avoid mistakes, it’s essential for coders to make sure all their information is up to date before submitting claims.

CCI EDITS: AN OVERVIEW

Some coders may wonder why the practice is not reimbursed for each CPT code when multiple procedures are performed on the same day or during the same session. The answer lies in National Correct Coding Initiative edits (often abbreviated NCCI or CCI). At the beginning of each January, April, July, and October, CMS publishes new CCI edits, which can affect how practices can code certain procedures.

The Centers for Medicare and Medicaid Services developed the CCI edits to promote national correct coding methodologies, prevent incorrect coding, and avoid inappropriate payments.¹ CCI edits bundle specific CPT codes when the procedures are performed by the same surgeon or group practice, in the same patient session, or at the same surgical site. But what about other payers? MACs, Medicare Advantage, and most commercial payers use these edits to review claims for irregularities during processing. Always verify coding edits with commercial payers.

Correct Coding Initiative edits can be downloaded on a Microsoft Excel table with 2 columns of codes. The CPT code in column 1 generally represents the major procedure or service performed. The CPT code in column 2 may represent a component of this code. Therefore, the code in column 2 may not be payable because its value is accounted for in the payment of the code in column 1.²

The table also includes the effective date and an indicator: 0 indicates that the codes are mutually exclusive and can never be unbundled, 1 indicates unbundling is allowed if certain criteria are met, and 9 indicates an error in the edit. When unbundling is appropriate, you must append modifier -59 (“Distinct procedural service”) to the CPT code in column 2. To meet the criteria for unbundling, documentation must support either a different session, a different procedure or surgery, a different site or organ, a separate incision or excision, or a separate injury.

In Table 2, CPT codes 92133 SCODI; optic nerve, and 92134 SCODI; retina have an indicator of 0, meaning that both tests can never be paid if performed on the same day. You should choose the test that provides the most information needed today as the code you submit for reimbursement.

The table also establishes that “CPT 67036 Vitrectomy, mechanical, pars plana approach” and “CPT 67145 Prophylaxis of retinal detachment without drainage; photocoagulation” are bundled with an indicator of 1. There may be instances when it would be appropriate to unbundle these two procedures, for example, if each were performed on the same patient but in different eyes.

When bundled codes are erroneously submitted to a payer, a denial may occur or the CPT code with the lower allowable is usually paid and the code or codes with higher allowables are denied. Developing a process to verify NCCI edits prior to claims submission will not only protect revenue but also ensure maximum reimbursement.

UNDERSTANDING GLOBAL PERIODS

Payers identify surgical procedures as either minor or major. Minor procedures have 0 or 10 days of postoperative care and major procedures have 90 days of postoperative for Medicare Part B. Payers that do not follow CMS rules may classify major procedures as 60 or 90 days of postoperative care.

Coverage for minor and major procedures is referred to as the global surgical package or global period. This package identifies what is included in the surgery and therefore not separately billable. It is also a good idea to have a process in place to ask about the global period for the procedure(s) being performed when the call is made to non-Medicare payers to obtain prior authorization.

The global period for surgical procedures can change periodically. For example, beginning January 1, 2022, “CPT 67141 Prophylaxis of retinal detachment without drainage; cryotherapy, diathermy” and “CPT 67145 Prophylaxis of retinal detachment without drainage; photocoagulation” changed from having a 90-day global period to having a 10-day global period for Medicare Part B.

Some commercial payers may also update the global period, while others may remain at 90 days. Promptly identifying the global period per CPT code and payer is essential to proper coding and reimbursement, because they can also impact how and when office visits are billed. Incorrectly assigning a 90-day global period to a CPT code for which the payer recognizes a 10-day global period would result in a loss of revenue because visits from 10 days out to 90 days would be inappropriately coded as postoperative and not billed.

KEEP SHARP

The rules for coding retina procedures are different from payer to payer and change over time. These differences and changes can cause big problems if the rules and updates aren’t identified, understood, and followed. By staying informed of developments, coders and billers can help prevent denials and protect the practice’s revenue. RP

REFERENCES

1. Centers for Medicare and Medicaid Services, Medicare national correct coding initiative (NCCI) edits. Accessed February 15, 2023. https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare
2. Edgar JS, Vicchrilli SJ. When do you bundle? how to understand CCI edits. American Academy of Ophthalmology. April 20, 2016. Accessed February 15, 2023. https://www.aao.org/young-ophthalmologists/yo-info/article/when-do-you-bundle-how-to-understand-cci-edits