Properly Coding Retina Surgeries

Identifying the diagnosis—not the procedure—is the first step when coding for retina surgeries.

By Joy Woodke, COE, OCS, OCSR
 

Two retina surgeries that use the same techniques and approaches may appear to be similar, but the CPT code that accurately reflects the surgery performed is often best identified by the diagnosis. For example, a pars plana vitrectomy (PPV) may be performed for a macular hole (MH), vitreous hemorrhage, or retinal detachment (RD), but each of these surgeries should be billed with different CPT codes depending on the diagnosis that led to the surgery. In this article I review a few examples of surgical retina procedures and describe how to code them accurately based on the diagnosis that led to the surgery.

AT A GLANCE

• Although surgical retina procedures may use similar techniques, the CPT code that accurately reflects the surgery performed is often best identified by the diagnosis that led to the surgery.

• A careful review of CPT code descriptors and confirmation of the diagnosis will lead to proper coding and payment for retinal surgery.

Pneumatic RETINOPEXY

A pneumatic retinopexy is performed by injecting a gas bubble into the vitreous. Typically, an anterior chamber tap is performed during the surgical session. Laser or cryotherapy may be performed during the session, but these are more commonly done postoperatively.

Code This Case

Patient: A 70-year-old woman presents with a black blotch in her field of vision and decreased vision in her right eye (OD) for 1 week. She has a history of bilateral wet age-related macular degeneration (AMD).

Diagnosis: Subretinal hemorrhage, AMD, and choroidal neovascular membrane (CNVM), OD.

Treatment Plan: Pneumatic displacement for subretinal hemorrhage and anterior chamber tap, OD (Figure 1).

Figure 1. A fundus photograph of a 70-year-old patient with a history of wet AMD who presented with a disrupted field of vision and decreased vision.

CPT CODE DESCRIPTORS FOR PNEUMATIC PROCEDURES

67110: Repair of retinal detachment by injection of air or other gas (eg, pneumatic retinopexy)

• RVU 25.09, Medicare nonfacility allowable $949.12 (varies by region)

• 90 day global

67025: Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure)

• RVU 20.85, Medicare nonfacility allowable $787.99 (varies by region)

• 90 day global

65800: Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous

• RVU 3.42, Medicare nonfacility allowable $129.54 (varies by region)

• 0 day global

Coding Options: The table to the right, CPT Code Descriptors for Pneumatic Procedures, shows full CPT descriptions for this diagnosis.

What to Consider: In this case, pneumatic retinopexy is performed to displace the subretinal hemorrhage. CPT code 67110, repair of RD by injection of air or other gas, is not correct. The surgical procedure was performed due to subretinal hemorrhage, and the description for 67110 requires the repair of an RD. The correct code for this case is 67025.

As a paracentesis of the anterior chamber was performed, submitting the code 65800 in addition to 67025 is correct; there is no National Correct Coding Initiative (NCCI) bundle. NCCI edits override separate procedure language for Medicare and other payers that follow Medicare’s rules.

Correct Coding: The correct coding for this case is 67025-RT and 65800-RT. Payment will be 100% of the highest allowable and 50% of the lower allowable.

Figure 2. Coding pneumatic cases begins with identifying the diagnosis.

Coding for pneumatic cases begins by considering the reason for surgery. Figure 2 outlines the decision tree for these cases. When the diagnosis is an RD, the correct CPT code is 67110. This code is bundled by the NCCI with either 67105 (laser) or 67101 (cryotherapy) performed during the same session.

If the diagnosis is subretinal hemorrhage or vitreomacular traction, the correct CPT code is 67025.

CPT CODE DESCRIPTORS FOR RETINAL LASER TREATMENTS

67105: Repair of a retinal detachment, including drainage of subretinal fluid when performed; photocoagulation.

67145: Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, one or more sessions; photocoagulation.

67210: Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; photocoagulation.

67220: Destruction of localized lesion of choroid (eg, choroidal neovascular membrane), one or more sessions; photocoagulation (eg, laser).

67228: Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation.

Retinal Laser Procedures

Coding for retinal laser procedures also requires consideration of the diagnosis. Although the same laser may be used in the clinic, multiple CPT codes may be considered, and the correct one is determined based on the reason for treatment.

Code This Case

Patient: A 75-year-old man is seen 3 days after pneumatic displacement for subretinal hemorrhage and CNVM, OD.

Diagnosis: Subretinal hemorrhage, AMD, and CNVM, OD.

Treatment plan: Diode laser, OD.

Coding Options: The table to the right, CPT Code Descriptors for Retinal Laser Treatments, shows full CPT descriptions.

What to Consider: In this case, the diagnosis leading to the laser procedure is CNVM. The correct CPT code is 67220.

Had the laser procedure been performed after a pneumatic retinopexy to repair an RD, the correct code would have been 67105. The decision tree in Figure 3 indicates the correct CPT codes for retinal laser based on the specific diagnosis leading to the treatment.

Abbreviations: CME, cystoid macular edema; DME, diabetic macular edema; PRP, panretinal photocoagulation; RD, retinal detachment.

Figure 3. Coding for retinal laser procedures begins with identifying the diagnosis.

Correct Coding: 67220-RT. Use modifier -58 if the laser was preplanned and documented preoperatively. If it was not, the -78 modifier would be correct.

PARS PLANA VITRECTOMY

PPV is a common procedure performed during retina surgery. To choose the correct CPT code for PPV, start by determining the reason for surgery. If the PPV is performed to repair an RD, consider the following codes:

• 67108: Repair of RD with vitrectomy (any method), including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique.

• 67113: Repair of complex RD (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction RD, retinopathy of prematurity, retinal tear of greater than 90°) with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens.

If the diagnosis is not RD, review the family of codes for vitrectomy, codes 67036 through 67043, below.

• 67036: Vitrectomy, mechanical, pars plana approach.

• 67039: Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation.

• 67040: Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation.

• 67041: Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (macular pucker).

• 67042: Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (for repair of MH, diabetic macular edema), includes, if performed, intraocular tamponade (air, gas or silicone oil).

• 67043: Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (choroidal neovascularization), includes, if performed, intraocular tamponade (air, gas or silicone oil) and laser photocoagulation.

What Is the Diagnosis?

If the diagnosis is epiretinal membrane, and a PPV with membrane peel is performed, the correct CPT code would be 67041—vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker).

If vitrectomy is performed with the removal of the internal limiting membrane for the repair of a MH, the CPT code that should be used is 67042—vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of MH, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil).

If the diagnosis is proliferative diabetic retinopathy and the surgeon performs removal of a vitreous hemorrhage by PPV and panretinal photocoagulation endolaser, the correct CPT code is 67040—vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation.

The Key to Accurate Surgical Procedure Coding

Although retinal surgical techniques may appear similar, the CPT code that should be billed for a given surgical procedure depends upon the diagnosis that led to that procedure. The key to correct coding is to first identify the reason for surgery. A careful review of CPT code descriptors and confirmation of the diagnosis will lead to proper coding and payment for the retinal surgery.

Joy Woodke, COE, OCS, OCSR
• AAO Practice Management Consultant
joywoodke@gmail.com
• Financial disclosure: None

 

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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.