Solutions For a Pair of Puzzling Surgical Coding Issues
A review of two common questions regarding coding for unique situations.
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.
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).
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.”
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 firstname.lastname@example.org.
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.