Solutions For a Pair of Puzzling Surgical Coding Issues

A review of two common questions regarding coding for unique situations.

By Riva Lee Asbell
 

The following questions and answers are based on queries from coding professionals at retina practices. The two issues presented are among the most frequently asked.

ISSUE No. 1 REMOVAL OF IMPLANTED MATERIAL

This issue involves the use of CPT codes 65920 (Removal of implanted material, anterior segment of eye) versus 67121 (Removal of implanted material,posterior segment; intraocular).

Q: I need some help with coding a surgery one of our doctors did yesterday that I have not seen before. A dexamethasone intravitreal implant (Ozurdex, Allergan) was implanted during an in-office procedure earlier this month and, after migrating to the anterior chamber, was removed in an outpatient hospital setting. A vitrectomy, paracentesis, and removal of the intraocular foreign body were performed. I am not sure which CPT procedure code and diagnosis code to use. Would it be CPT code 65235 (Removal of foreign body, intraocular; from anterior chamber of eye or lens) and ICD-9-CM diagnosis code 360.61 (Retinoschisis and retinal cysts)? I am not sure about the “foreign body” removal; a dexamethasone intravitreal implant is something that is purposely placed in the eye, so is it not implanted material?

A: The correct coding for this case is CPT codes 67036 (Pars plana vitrectomy) + 65920 (Removal of implanted material, anterior segment of eye) using ICD-9-CM diagnosis 996.59 (Mechanical complication of other specified prosthetic device, implant and graft/due to other implant and internal device, not elsewhere classified).

Explanation: Although the implant was originally placed in the posterior segment, the case should be coded using CPT code 65920 because the implant had migrated and was removed from the anterior segment. The following note appears in the CPT manual after code 65235 (Removal of foreign body, intraocular; from anterior chamber of eye): “For removal of implanted material from anterior segment, use 65920.” It is very important for physicians and ancillary staff to use the CPT manual as the primary coding source.

CPT code 67028 (Intravitreal injection of pharmacologic agent) is the code used for insertion of a dexamethasone intravitreal implant, and this code has a global period of 0 days for Medicare; thus, it is not necessary to use any of the global period modifiers (58, 78, or 79).

In a situation such as the one outlined above, it is important to understand the definition of a foreign body. In the world of coding, a foreign body is an object that has entered and is present in the body but does not belong there and was not placed by a surgeon. This includes objects that are either synthetic or natural (wood, glass, metal, etc.). These objects are present in the body as a result of trauma. In ophthalmology, the list of sites in which a foreign body may be found includes the cornea, conjunctiva, and orbit; foreign bodies may also be intraocular or embedded in lacerations. Obviously, these objects arrive in the body part as a result of some type of trauma, such as an accident, natural force (wind blowing something in the eye), or other external method of delivery.

An implant, on the other hand, is a manufactured object that has been placed by a surgeon as part of a surgical procedure. When there are complications related to the placement of the implant, its removal is often the procedure of choice. Thus, one should not code the removal of an implant as removal of a foreign body.

Proper Use of Phacoemulsification Codes and Modifier 59

  • Use CPT code 66850 for phacoemulsification procedures performed in conjunction with pars plana vitrectomies (67036–67043) when an intraocular lens is not being placed.
  • Use 66984 (Cataract extraction with IOL) or 66982 (Cataract extraction with IOL, complex) when an IOL is inserted in conjunction with retinal detachment repair (CPT code 67108 [Repair of retinal detachment with vitrectomy, etc.]). You have to append modifier 59 in order to get paid for cataract extraction and IOL insertion when they are performed in conjunction with retinal detachment repair because the codes are bundled under the National Correct Coding Initiative. Alternatively, the new X modifiers (XS or XU) may also qualify.
  • Using code 66852 will result in denials of that code when it is used for coding combination vitrectomy surgeries because it is bundled in the NCCI with the pars plana vitrectomy codes. Therefore, do not use modifier 59 or the X subset codes for coding lensectomies with pars plana vitrectomies. However, you will have to use modifier 59 and the X subset codes when performing cataract extractions with insertion of an IOL in conjunction with a pars plana vitrectomy.

Examples of specific CPT codes that address removal of implanted material that a retinal surgeon might use include 65920 (Removal of implanted material, anterior segment of eye), 67120 (Removal of implanted material, posterior segment, extraocular), and 67121 (Removal of implanted material, posterior segment, intraocular).

Examples of specific CPT codes that address removal of foreign bodies (and thus codes that would not be applicable to the situation in question) include 65235 (Removal of foreign body, intraocular; from anterior chamber of eye), 65260 (Removal of foreign body, intraocular; from posterior segment, magnetic extraction), and 65265 (Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction).

CASE STUDY

A patient previously had cataract surgery on the left eye and was referred to a retina specialist presenting with a wound leak, retained lens fragments in the posterior vitreous, and intraocular lens (IOL) dislocated into the posterior vitreous. Surgery was performed that consisted of pars plana vitrectomy, focal endolaser placed between the equator and ora serrata, removal of the crystalline lens fragments (with a fragmatome), and repositioning of the IOL.

Diagnoses:

  1. 1) 998.82 Retained lens fragments, left eye
  2. 2) 996.53 Mechanical complication of implanted material: intraocular lens, left eye
  3. 3) V45.69 Previous surgical procedure, left eye

Surgery:

Tips:

  • Some Medicare Administrative Contractors (MACs) do not require modifier 51.
  • See “Complicated Coding Issues in Combined Lens and Retina Surgery” in the April 2014 issue of Retina Today for further clinical examples.
  • See “CMS Updates for Modifier 59 Subsets: XE, XP, XS, XU” for the latest information on use of the X subsets in place of modifier 59. Some MACs have provided clinical examples, but the CMS so far has not. Either modifier 59 or XU can be used to break the NCCI bundles of 66850 and 66825 because the repositioning of the IOL usually does not overlap the removal of lens material.

Issue no. 2 CRYSTALLINE LENS OR LENS FRAGMENT REMOVAL IN CONJUNCTION WITH VITREORETINAL PROCEDURES

This section concerns the use of CPT codes 66850 (Removal of lens material; phacofragmentation technique [mechanical or ultrasonic]) versus 66852 (Removal of lens material; pars plana approach, with or without vitrectomy).

Q: I considered using code 66850 for the removal of a crystalline lens that dropped into the posterior vitreous. My choice was made solely on the CPT directives, but, upon consulting a physician, he stated that code 66852 is more appropriate. Which code is correct in this situation?

A: CPT code 66850 should be used.

Explanation: The CPT manual is quite specific in noting that CPT code 66850 is used when a lensectomy is performed in conjunction with a vitrectomy procedure; this is based solely on CPT instructions. The instruction, found following the description of CPT code 67043 (Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina), applies to all the pars plana vitrectomy codes. The instruction states, “For associated lensectomy, use 66850.”

CMS Updates for Modifier 59 Subsets: XE, XP, XS, XU

The Centers for Medicare and Medicaid Services (CMS) has clarified that it does not want to receive codes employing the 59-X format. CMS has stated that claims should be coded using either the 59 modifier or one of the X subset modifiers.

Some Medicare Administrative Contractors have published suggested examples; however, CMS had not published any clinical examples at this time. The examples used in the article “New Modifier 59 Coding Revisions” in the November/December 2014 issue of Retina Today should be coded with either modifier 59 or one of the subsets indicated, but not both.

Furthermore, all the vitrectomy codes are bundled in the National Correct Coding Initiative (NCCI) with 66852, and should not be unbundled. Code 66852 will be denied, whereas code 66850 will be paid when used to code the lens removal with the pars plana vitrectomy codes.

Most retina surgeons, billers, and even consultants instinctively want to use 66852 because “pars plana approach” is incorporated into the description. CPT code 66852 specifically states “with or without vitrectomy” because the code was developed to code primary cataract and anterior vitreous removal using various instrumentation techniques in response to this procedure being advocated and developed by Louis J. Girard, MD, in 1979.1 Incidental or planned anterior vitreous may be removed, but a core or complete vitrectomy, as performed today, is not used. For tips on how to code another type of late cataract complication, see Case Study. n

Riva Lee Asbell is the principal of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm in Fort Lauderdale, Florida. Ms. Asbell may be reached at rivalee@rivaleeasbell.com.

CPT codes copyright 2014 American Medical Association.

1. Girard, L.J. Lensectomy through pars plana by ultrasonic fragmentation (USF). Ophthalmology. 1979;86(11):1985-1993.

 

Contact Info

Bryn Mawr Communications LLC
1008 Upper Gulph Road, Suite 200
Wayne, PA 19087

Phone: 484-581-1800
Fax: 484-581-1818

Karen Roman
Editor-in-Chief
484-581-1827
kroman@bmctoday.com

Janet Burk
Publisher
214-394-3551
jburk@bmctoday.com

About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.