Surgery
on both eyes on different dates means 2 global periods -- and hundreds
in reimbursement at stake
As
an ophthalmology coder, you’ll likely code cataract procedures more
often than any other surgery. With several possible surgical
treatments, however, there’s a lot of room for error -- which can
equate to more than $600 at stake for cataract procedures in 2008.
Use
these tricky scenarios as a guide through some of the most problematic
cataract coding situations.
Append
79 for Surgery in Fellow Eye
Scenario
1:
On Feb. 1, an ophthalmologist performs an extracapsular cataract
removal with IOL insertion on a patient’s right eye. One month later,
on March 1, he performs the same surgery on the patient’s left eye.
Problem:
The
cataract procedure, 66984 (Extracapsular cataract removal with
insertion of intraocular lens prosthesis [one stage procedure], manual
or mechanical technique [e.g., irrigation and aspiration or
phacoemulsification]), has a 90-day global period, says Kimberly
A. Lewis, CPC, OCS, coder for the Duke University Health System in
Durham, N.C. To report 66984 performed on the left eye a month after
the original surgery, you’ll need a modifier -- but which one?
Solution:
Because the two surgeries seem related, you may be tempted to append
modifier 78 (Unplanned return to the operating/procedure room by the
same physician following initial procedure for a related procedure
during the postoperative period) to the second cataract surgery,
but that would be a mistake. The surgery in the left eye is unrelated
to the initial surgery in the right eye.
The
best option here would be modifier 79 (Unrelated procedure or
service by the same physician during the postoperative period),
Lewis says.
Remember
also to append the "side" modifiers, LT (Left side) or RT (Right
side), to demonstrate that the ophthalmologist performed the
procedures on opposite eyes. Report 66984-RT for the first surgery and
66984-79-LT for the second cataract surgery, says Maggie M. Mac,
CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and
Associates in Clearwater, Fla.
Reimbursement
for 66984 would be about $661.95, based on 17.38 relative value units
(RVUs) multiplied by the 38.0870 conversion factor.
Report
Related Procedures With 78
Scenario
2:
On May 10, the patient in Scenario 1 presents with after-cataracts in
his left eye. The ophthalmologist incises the posterior capsule with a
YAG laser.
Problem:
The
global period for the original cataract surgery expired before May 10.
Do you need to append a modifier to the YAG capsulotomy? If so, which
one?
Solution:
In this case, the global period for 66984-RT is over -- but the patient
is still in the postoperative period for 66984-LT.
When
the ophthalmologist performed 66984 on the left eye on March 1, a new
90-day global period started, which would end at the end of May.
Report
code 66821-LT-78 (Discission of secondary membranous cataract
[opacified posterior lens capsule and/or anterior hyaloid]; laser
surgery [e.g., YAG laser] [one or more stages]; left side).
If
the patient also had after-cataracts in his right eye, you would code
66821-RT-79. That procedure, although occurring within the global
period of 66984-LT, is unrelated to it, warranting the use of modifier
79. The global period for the related procedure, 66984-RT, would have
already expired.
Document
Necessity for Planned Vitrectomy
Scenario
3:
During the course of a cataract removal, the vitreous collapses, and
the ophthalmologist finds he must perform a vitrectomy.
Problem:
Can you code separately for the vitrectomy?
Solution:
The answer depends on whether the vitreous collapse was an iatrogenic
(inadvertently introduced) complication.
Ophthalmologists
often have to perform a vitrectomy during cataract surgery due to
vitreous collapse in the course of removing a dense, senile cataract.
In those cases, Medicare considers the vitrectomy a component of the
cataract surgery, and thus not separately payable.
The
Correct Coding Initiative (CCI) bundles vitrectomy codes 67005 (Removal
of vitreous, anterior approach [open sky technique or limbal incision];
partial removal) and 67010 (… subtotal removal with mechanical
vitrectomy) into cataract surgery codes 66982 (Extracapsular
cataract removal with insertion of intraocular lens prosthesis [one
stage procedure], manual or mechanical technique, complex ...) and
66984.
Exception:
If a prolapsed vitreous exists and is known in advance -- and
documented in the patient medical record -- don’t consider it a
complication of the cataract surgery, says Nancy LaVergne, CPC,
OCS, CAPPM, coder for Jackson Eye Associates in Missouri.
Therefore,
the physician who plans to perform a vitrectomy during the same
operative session as cataract surgery could code separately for the
vitrectomy using modifier 59 (Distinct procedural service):
67005-59 or 67010-59.
Key:
Documentation
and diagnosis codes can get you reimbursement. Use 379.26 (Vitreous
prolapse) for the vitrectomy and the appropriate cataract diagnosis
for the cataract removal.
Be
prepared to provide documentation in case you receive denials when
using these codes together, despite the use of modifier 59. Payers are
aware of the potential for 59 abuse and may want you to go through the
review process to prove you’ve met the definition of "distinct
procedural service."
Provide
the chart notes to show that the vitreous collapse was known in advance
and that the surgeon planned to repair it prior to the surgical
session. Also, provide the operative report with clear documentation
showing that the vitreal prolapse was a known pre-operative diagnosis
in addition to the cataract surgery, which made the vitrectomy
medically necessary.
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