Coding retina case studies can often be difficult, especially when it comes to identifying the correct answer. For example, when multiple procedures are performed on the same day, National Correct Coding Initiative (NCCI) bundles should be considered. Unique payer policies may also affect correct coding. Here are five scenarios that have stumped your peers. From commercial carrier denials to missing information, these scenarios present a variety of coding challenges that require careful consideration. Can you identify the correct answer?
CASE STUDY NO. 1
The following current procedural terminology (CPT) codes were billed for the same surgical session:
- 67036, vitrectomy, mechanical, pars plana approach
- 66985, insertion of IOL prosthesis (secondary implant), not associated with concurrent cataract removal
- 66682, suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel suture)
These three codes are not bundled under NCCI. However, the commercial carrier denied CPT code 66682. Why?
A. The payer does not cover this procedure.
B. There is separate procedure language in the CPT code descriptor.
C. The procedure is incidental to the secondary implant.
D. The payer bundles this procedure with the vitrectomy.
CASE STUDY NO. 2
The superbill states an injection of triamcinolone (Kenalog) was performed in the right eye. What else do you need to know to code this case?
A. The type of injection.
B. The medication dosage.
C. If it was single-use or a multidose vial.
D. All the above.
CASE STUDY NO. 3
Medicare denied the removal of silicone oil in the global period of retinal detachment surgery in the same eye. The case was reported as CPT code 67036–78-RT, pars plana vitrectomy (PPV) and ICD-10 code T85.39XA, other mechanical complication of ocular implants. Why was this claim denied?
A. Incorrect modifier
B. Incorrect CPT code
C. The ICD-10 code is not included in the national coverage determination (NCD) for CPT code 67036
D. Medicare does not cover surgery in the global period
CASE STUDY NO. 4
A patient is evaluated for floaters in both eyes. A medically appropriate history and examination are performed along with bilateral extended ophthalmoscopy, including a detailed drawing and labels of the pathology. The diagnosis is a posterior vitreous detachment in the right eye and a retinal tear in the left eye. The plan is to laser to repair the retinal tear. How should you appropriately code this case?
A. 99204–25, 92201–59, 67145-LT
B. 99204–57, 67145-LT
C. 99204–25, 92201, 67145-LT
D. 67145-LT
CODING QUICK LINKS
CASE STUDY NO. 5
The retina specialist performed a vitrectomy with internal limiting membrane (ILM) peel and then placed an amniotic membrane under the macular hole in the right eye. What is the correct way to code this?
A. 67041-RT, PPV with removal of preretinal cellular membrane (eg, macular pucker)
B. 67042-RT, PPV with removal of ILM of retina (eg, for repair of macular hole, diabetic macular edema)
C. 67042-RT and 65778-RT, placement of amniotic membrane on the ocular surface, without sutures
D. 67042-RT and 67299-RT, unlisted procedure, posterior segment
ANSWERS AND DISCUSSION
Case No. 1 Answer: B
Although Medicare will not deny due to separate procedure language, many commercial plans will. These plans don’t expect CPT codes with separate procedure language to be reported when any other procedure is performed on the same day.
Case No. 2 Answer: D
If any of this information is missing, not only do you lack the information necessary to code the case, the documentation is incomplete if audited. First, confirm if an intravitreal injection (CPT 67028) or a sub-tenon injection (CPT 67515) was performed. Next, check the dose of triamcinolone and the vial used, either single-use or multidose. Triamcinolone is reported with HCPCS J3301 and the descriptor “injection, triamcinolone acetonide, not otherwise specified, 10 mg.” If a multidose vial was used for 4 mg, report 1 unit for the medication used, which would include a dosage of 10 mg or less. For a single-use vial that includes 40 mg and a dosage of 4 mg and 36 mg wasted, report J3301 1 unit and J3301–JW 3 units.
Case No. 3 Answer: C
Per the Medicare NCD for vitrectomy (80.11),1 T85.398XA is not a covered diagnosis.2 Instead, report the retinal detachment ICD-10 diagnosis as the primary diagnosis and the reason for the surgery; report T85.398XA as secondary.
Case No. 4 Answer: A
Extended ophthalmoscopy, CPT code 92201, is bundled the same day as CPT code 67145 with an indicator of 1, comprehensive, which means that there may be circumstances appropriate to unbundle.3 When performed in the fellow eye and pathology is documented, it is appropriate to unbundle with modifier –59, or –XS (separate structure) per the payer preference. Make sure that you link the ICD-10 code for the fellow eye only to CPT code 92201 to justify unbundling the two procedures.
Case No. 5 Answer: D
CPT code 67042 is the appropriate code for a PPV with ILM removal. There is no CPT code that represents the placement of amniotic membrane under the macular hole. Report CPT code 67299 (unlisted procedure, posterior segment) and submit the operative report to the payer for review.
RINSE, REPEAT
So, how did you do? Retina coding is a complex field that requires attention to detail and a comprehensive understanding of coding guidelines. By reviewing these five case studies, you can better understand common coding challenges and the steps required to overcome them. As always, it is important to stay up to date with the latest coding guidelines and seek the advice of a qualified coding specialist when necessary. To review more cases, visit www.aao.org/practice-management/coding-news.
1. Vitrectomy. CMS.gov. Accessed April 3, 2023. www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=18&ncdver=2&bc=0
2. CMS Manual System: Pub 100-20 One-Time Notification. Department of Health & Human Services (DHHS). Centers for Medicare & Medicaid Services (CMS). November 9, 2018. Accessed April 3, 2023. www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2202OTN.pdf
3. Medicare National Correct Coding Initiative (NCCI) Edits. CMS.gov. Accessed April 27, 2023. www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare
