For physicians, patient care is of course the primary concern; however, business practices must be considered to maintain the financial health of a practice and/or ambulatory surgical center. Reimbursement remains an important issue in vitreoretinal surgery, and how a procedure is coded, bundled, or modified is crucial to that effect. In this first issue of the new year, Riva Lee Asbell provides an update on surgical coding for 2009, outlining some important definitions and selection and pairing tips to ensure proper coding and reimbursement. -Pravin U. Dugel, MD

Reimbursement for vitreoretinal surgical procedures has been slashed so dramatically that the surgeon needs to allot some time and energy to mastering some of the crucial points in reimbursement. The decrease has resulted not only from the re-evaluation of the new Current Procedural Terminology (CPT) surgical codes in 2008, but also as a result of the code pair edits—or the "bundles" —that occurred in version 14.3 of the National Correct Coding Initiative (NCCI), effective October 1, 2008.

Let's take a look at some of the issues facing you. This review applies to Medicare and may not be the same for other insurers.

NCCI
Background. The NCCI, essentially a document that pairs CPT codes that cannot be coded together, is now in its 15th year. You should be familiar with it by this time. When a code pair exists it may be classified as Column I–Column II Codes or Mutually Exclusive Codes. In both types, you will only be paid for one set of codes.

Definitions. Column I–Column II Codes code pair edits include all related services. When coding, one should not fragment one service into component parts to maximize reimbursement. Because this was being done in excess (that is, fraudulently), the NCCI was developed. An example of this would be 67108 (retina detachment repair by vitrectomy) with 66850 (lensectomy by phacoemulsification).

Mutually Exclusive Codes are code pair edits that cannot reasonably be performed at the same anatomic site or in the same patient encounter. This is based either on the Healthcare Common Procedure Coding System (HCPCS)/CPT code descriptors or the medical impossibility or improbability that the two procedures could be performed at the same patient encounter.

Caution: With Column I Codes, you are paid the highest code and not for the bundled code; however, with Mutually Exclusive Codes, you are paid the lowest paying code (code with lowest relative value units [RVUs])!

Tip: The bundles that were issued on October 1, 2008 are Mutually Exclusive. If they are inadvertently billed together you will be paid for the lowest paying one with little recourse to reverse the billing.

Clinical Application. The most serious mutually exclusive bundle is 67040 (endolaser PRP) and 67041 (PPV with epiretinal membrane removal). CPT code 67040 is also bundled mutually exclusively with 67042 (macular hole) and 67043 (subretinal membrane removal). For practices that do not have a code editor built into the billing system please be diligent about this. The surgeons must be aware of this and check the appropriate code—not check every code they think may apply and let the billing department select the correct one.

ASC Impact. There will be a negative impact on your ambulatory surgical center (ASC) billing, particularly when the laser is used in conjunction with the other procedures. It is important to study potential revenue impacts and base your code selection on the outcome.

Breaking the Bundles. Yes, you can override the code edit pairs by applying modifier 59. I strongly advise against this. You will have to do it on every case, and surely you will find yourself in an unpleasant audit situation. The use of modifier 59 has been of great interest to the Office of the Inspector General and you really do not want to be the focus of their attendance.

The Reimbursement. The chart above gives you the national average reimbursement for the codes discussed in this article.

COMPLEX RETINAL DETACHMENT (CPT CODE 67113)
When I audit practice, I often finding that either a preponderance of cases that should be coded with CPT Code 67113 are not coded as such or that cases are coded as complex but do not meet the qualifications. First and foremost, 67113 is not a code to be used simply because the case was difficult or you encountered complications. For the most part, it is used when the surgeon knows prospectively that the case is going to be complex. This is parallel to the use of the complex cataract extraction code.

The code descriptor in CPT reads as follows:

"67113 Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens."
Here are some tips to assist you in proper code selection:
  • CPT code 67113 essentially is 67108 with epiretinal membrane stripping.
  • CPT code 67113 pays more than 67108. There was a math error initially in 2008, but by the time the fee schedules were in effect it was remedied.
  • CPT code 67113 replaces the old combination of CPT codes 67108 plus 67038.
  • Do not use CPT codes 67108 plus 67041 with modifier 59 to break the bundle. CPT codes 67108 and 67041 are bundled, and constant use will lead to an audit.
  • Code 67043 (PPV/removal of subretinal membrane) is performed by few practitioners and even less with the advent of intravitreal injection of bevacizumab (Avastin, Genentech) and ranibizumab (Lucentis, Genentech). It is bundled into CPT Code 67113. Code 67043 is not used for retinal detachment repair.
  • Chart Documentation: Be sure to document in the chart the clinical conditions preoperatively when possible and in the operative notes.

CASE STUDIES
Case 1. Patient had a history of proliferative diabetic retinopathy, localized epiretinal membranes and cataract in the left eye. Surgery consisted of: (1) phacoemulsification cataract extraction with insertion of an intraocular lens; (2) lysis of posterior synechiae; (3) pars plana vitrectomy with epiretinal membrane peeling; (4) panretinal endolaser photocoagulation; (5) peripheral cryopexy; (6) air-fluid exchange. All procedures were performed in the left eye. Code all procedure(s).

Tips: The epiretinal membrane peeling (CPT code 67041) is no longer billed since it is bundled mutually exclusively with CPT code 67040. Complex cataract code is used in cases in which the surgery is complex and not for complications encountered during cataract surgery. Use supporting diagnosis, such as posterior synechiae in this example.

Case 2. Patient had diagnoses of rhegmatogenous retinal detachment with proliferative vitreoretinopathy. Surgery consisted of retinal detachment repair by (1) pars plana vitrectomy; (2) epiretinal membrane peeling; (3) cryopexy; (4) air fluid exchange; (5) 16% C3F8 gas. All procedures were performed in the right eye. Code all procedure(s).

Tip: Complex retinal detachment repair essentially consists of pars plana vitrectomy and epiretinal membrane peeling. Other procedures are included via NCCI bundling.

Case 3. Patient presented with dropped nucleus in the vitreous that occurred during cataract surgery the previous day. Surgery consisted of (1) pars plana vitrectomy; (2) removal of retained lens material by phacoemulsification. All procedures were performed in the right eye. Code all procedure(s).

Tip: CPT code 66852 (Removal of lens material, pars plana approach) is not your code! It was designed for primary cataract lens extraction using a pars plana approach. It is bundled with CPT code 67036. Follow CPT instructions for the vitrectomy codes and use CPT code 66850.

Riva Lee Asbell is Principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. Ms. Asbell has a financial interest in products mentioned in "Additional Reading." She can be reached through her Web site at www.RivaLeeAsbell.com.

Pravin U. Dugel, MD, is Managing Partner of Retinal Consultants of Arizona and Founding Member of the Spectra Eye Institute in Sun City, AZ. He is a Retina Today Editorial Board Member. Dr. Dugel can be reached via e-mail at pdugel@gmail.com.

Additional Reading
Asbell RL. Tips on Ophthalmic Surgical Coding by Subspecialty. * This book has an extensive chapter on Retinal-Vitreal Surgical Coding as well as global concepts including modifiers and NCCI. Published by the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Administrators. Order form available on Riva Lee Asbell's web site or from www.asoa.org. Purchase through ASOA by contacting Susan Younker 703-788-5759.

Visit ASOA Web site for electronic product with NCCI bundles entitled Eye Coding Today.