Billing pediatric retina cases can be complex, especially when dealing with retinopathy of prematurity (ROP). This article explores 3 common scenarios in pediatric retina cases and provides essential coding and billing guidance. It will explain the criteria for appropriate evaluation and management (E/M) code selection in both the inpatient and outpatient setting and discuss the use of modifiers for procedures such as anti-VEGF injections and laser treatments.

RETINOPATHY OF PREMATURITY INPATIENT EXAMINATION WITH INJECTION

A pediatric ophthalmologist conducts a follow-up evaluation for ROP in a premature infant in the local hospital’s Neonatal Intensive Care Unit (NICU). During the examination, the physician employs extended ophthalmoscopy with scleral depression in both eyes. Documentation reveals progressing intravitreal neovascularization in the left eye, while the right eye remains in zone 1 stage 2 without plus disease. Based on this information, the physician decides to administer an anti-VEGF injection in the left eye.

The first consideration when coding is to identify the payer, as Medicaid and other payers may have varying coverage rules. As the examination takes place in the NICU, traditional outpatient E/M codes are not suitable. Instead, inpatient hospital E/M codes should be used. Since January 1, 2023, inpatient E/M codes have the same criteria as office-based E/M codes.

The level of E/M, in any location, is determined by the physician’s total time or medical decision-making (MDM); the only exception is the emergency department, where the only consideration is MDM. When the level of E/M is determined by MDM, 3 elements are involved: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications or patient management. In this case, a chronic illness with progression corresponds to moderate complexity in the problem category, while the risk of performing an anti-VEGF injection is considered moderate as well due to the prescription drug management. With 2 components at the moderate level (problems and risk), the overall risk is moderate, so the appropriate inpatient E/M CPT code is 99232.

Additional coding considerations include national correct coding initiative (NCCI) edits that bundle the extended ophthalmoscopy code (CPT 92201) with the intravitreal injection code (CPT 67028) when both are performed on the same day. If the examination is conducted solely to confirm the need for the injection, then although medically necessary, the exam is not billable. In this case the exam and extended ophthalmoscopy were performed to address disease in both eyes, therefore it would be appropriate to append the modifiers -25 to the examination (as “significant separately identifiable”) and -59 to the ophthalmoscopy (as “performed in a separate structure or fellow eye”) (Table 1).

RETINOPATHY OF PREMATURITY INPATIENT EXAMINATION WITH LASER

A pediatric ophthalmologist conducts a follow-up ROP examination for a premature infant in the NICU. During the extended ophthalmoscopy with scleral depression in both eyes, the physician documents intravitreal neovascularization with progression for zone 1 stage 3 without plus disease in both eyes. After discussing the situation with the parents, the physician decides to proceed with laser surgery in both eyes on the same day.

Similar to the first case described, the level of E/M in this scenario is determined by medical decision-making components. In this instance, a chronic illness with progression leads to moderate complexity in the problem category. The amount of data is considered low, as the parents provided information and hospital records were reviewed. The decision to perform laser surgery is considered a moderate risk. With problems classified as moderate, data as low, and risk at the moderate level, the appropriate E/M code is 99232.

Coding considerations involve appending modifier -57 to the E/M code 67229, indicating that the visit was used to determine the need for the laser procedure, which has a 90-day global period. Additionally, proper correct coding initiatives bundle the extended ophthalmoscopy (CPT 92201) with the laser procedure (CPT 67229). In this case, where both eyes are being examined and treated, it is not appropriate to unbundle with modifier -59 (Table 2).

RETINOPATHY OF PREMATURITY EXAMINATION IN THE OFFICE

A premature baby arrives at the pediatric ophthalmologist’s office for a follow-up evaluation for ROP. The parents accompany the baby for the problem-focused examination. The physician performs extended ophthalmoscopy on both eyes and uses scleral depression to aid the examination. The detailed drawing with labels and documentation reveals a raised ridge between the vascular and avascular retina in both eyes. The diagnosis is identified as zone 1, stage 2 ROP in both eyes, necessitating follow-up in 1 week. The physician emphasizes the critical importance of strict compliance with return visits for proper monitoring and treatment of the condition.

As this examination is performed in the office, ophthalmologists have 2 types of visit codes to choose from: the outpatient E/M CPT codes or the Eye Visit codes. When either E/M or eye visit codes can be billed, consider billing the code with the highest allowable for that payer. (For more information on how to appropriately maximize reimbursement, see “How to Choose Between E/M and Eye Visit Codes” at https://www.aao.org/young-ophthalmologists/yo-info/article/how-to-choose-between-e-m-eye-visit-codes-2 .)

In this case, the number of problems is moderate with a chronic illness with progression. The data are low, with reporting from an independent historian. The risk of complications is also low, monitoring ROP with a follow-up in 1 week. The overall level of examination is low, which equates to a level 3 established patient E/M code, 99213. The extended ophthalmoscopy, CPT 92201, is also billable for this visit without any modifiers.

For all 3 of these cases, it’s important to know your payer’s rules. Different payers, especially commercial payers, have varying coverage rules for pediatric retina cases. Ensure you are familiar with the specific guidelines of the payer to avoid claim denials and reimbursement issues. Also, link the appropriate ICD-10 code to the CPT code to support medical necessity and justify the procedure or examination. Accurate documentation of the patient’s diagnosis enhances reimbursement and minimizes claim denials. Regularly update the ICD-10 code as the patient’s condition changes for precise billing and compliance. By understanding the coding principles and utilizing the appropriate modifiers, health care providers can navigate the complexities of pediatric retina coding and billing with greater ease and accuracy. RP