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Staying informed about the nuances of retina coding can be challenging. CPT and ICD-10 codes change, insurance carrier policies are updated, and unusual cases may present. Here are several common or unique inquiries I have received recently from retina practices.
Should I bill place of service 21, inpatient hospital, even though the patient with inpatient status is seen in the office for an injection?
You must bill place of service (POS) 21 for a patient with inpatient status. CMS stated this in a transmittal:
When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS [ie, Physician Fee Schedule] at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient.
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How do we bill for testing services that include “unilateral or bilateral” in their language?
When a code descriptor states “unilateral or bilateral,” such as CPT code 92250 (Fundus photography) or 92201 (Extended ophthalmoscopy with scleral depression of peripheral retinal disease), the code is considered inherently bilateral. Whether you test one or both eyes, you should submit the service only once. Modifiers -RT, -LT or -50 should not be appended and may cause denials.
I performed pneumatic displacement to address a submacular hemorrhage. What are the appropriate CPT codes?
Because there is no retinal detachment as seen with a pneumatic retinopexy (67110), the appropriate claim submission is CPT codes 67025 (Injection of vitreous substitute, pars plana or limbal approach, [fluid-gas exchange], with or without aspiration [separate procedure]) and 65800 (Paracentesis of anterior chamber of eye).
I performed an Nd:YAG laser procedure in the office to treat vitreous opacities. The patient has never undergone cataract surgery. What code do I use?
There are reasons other than capsular haze for using an Nd:YAG laser. Submit CPT code 67031 (Severing of vitreous stands, vitreous face adhesions, sheets, membranes or opacities, laser surgery [-1 or more stages]). This is known as Nd:YAG vitreolysis.
Surgeon A performed cataract surgery 1 week ago. During the postoperative visit, the patient complained and displayed signs and symptoms of cystoid macular edema. The patient was referred to a retina specialist (Surgeon B) in the same group. Surgeon B performed an examination, ordered OCT imaging, and began treating the patient. From Surgeon B’s perspective, is this part of postoperative care or is this a billable examination?
Physicians of the same group share postoperative care. Only the retina OCT and treatment are billable. Billing the examination with modifier -24 (unrelated examination in the postop period) would not be appropriate, as the diagnosis is related or a complication of the cataract surgery.
Can we unbundle CPT codes 67036 (Pars plana vitrectomy) and 67145 (Prophylaxis of retinal detachment; photocoagulation) with modifier -59 if these procedures were performed during the same session?
CPT code 67145 has been bundled with 67036 since 1996. It is inappropriate to unbundle due to treatment of contiguous structures. Instead, bill CPT code 67039 (Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation).
When is it appropriate to unbundle CPT 67028 (Intravitreal injection) and 92201 (Extended ophthalmoscopy with scleral depression of peripheral retinal disease)?
It is appropriate to unbundle these two codes when the extended ophthalmoscopy with pathology is performed in the eye that did not receive an injection.
Can I bill for both CPT codes 92273 (Electroretinography [ERG], full field) and 92274 (ERG, multifocal) the same day?
There is no bundling edit for this situation. Physicians should clearly indicate why the two tests are medically necessary. Documentation may be requested. Payers do not expect to see this often.
If my office billed CPT code 67105 (Laser for detached retina) for a patient and that patient returned within the global period presenting with pathology that requires laser for detached retina, can our office bill for the laser again?
Even though the language “one or more sessions” was removed from the description for CPT code 67105, payers still expect to see only one laser billed during the 10-day global period.
I performed same-day bilateral repair of a retinal tear on a patient with Medicare coverage and used CPT code 67145 (Repair of retinal tear) for billing. The first claim I submitted was: 67145-RT, 67145-LT. When the payer denied it, I resubmitted: 67145-RT, 67145-LT-51. The payer also denied the second claim. What is the best way to submit this case?
Beginning in 2013, Medicare Part B has required all bilateral surgical procedures to be submitted as a single line, 67145-50 with a 1 in the unit field and double the charge. Medicare will pay 150% of the allowable. If this is not submitted properly, payment may be denied or may be at 100% of the allowable rather than at 150%. Commercial payers vary in their requirements. Some prefer two lines with -RT and -LT modifiers. There is no need to append modifier -51; most payers’ systems are sophisticated enough to recognize multiple procedures in the same setting.