Reimbursement for Intravitreal Drug-Delivery Implants
ANSWERS PROVIDED BY RIVA LEE ASBELL
Q. How can I get paid for the new technology drugs such as Retisert that are being implanted in much the same fashion as Vitrasert and fluocinolone?
A. This is not really too much of a coding challenge.
The correct CPT (Current Procedural Technology) code is:
► 67027: Implantation of intravitreal drug-delivery system (e.g., ganciclovir implant), includes concomitant removal of vitreous
For removal of drug-delivery implants use CPT code 67121.
Of importance is the fact that the procedure entails some incidental removal of vitreous and that the pars plana vitrectomy should not be coded additionally. I have encountered exceptions to this, such as in the following example:
The patient had a history of panuveitis with a cyclitic membrane in the left eye. She also had previously undergone cataract extraction, but not within the global period. Surgery consisted of complete vitrectomy, removal of the cyclitic membrane using a pars plana approach, and implantation of the fluocinolone implant.
The case would be correctly coded as follows:
360.12: Panuveitis, left eye
364.8: Cyclitic membrane, left eye
67027: Insertion of fluocinolone implant left eye LT
67036: Pars plana vitrectomy left eye 51-59-LT
66830: Removal of cyclitic membrane left eye 51-59-LT
Some coders may prefer to use 66999 rather than 66830, but the principal issue is that because a complete vitrectomy was performed one uses CPT code 67036 and unbundles the code pairs by appending modifier –59. The same unbundling is performed because CPT codes 67036 and 66830 are code-pair edits.
Under ordinary circumstances the vitrectomy is not coded. If an exchange of the implant is performed, then CPT code 67027 is used in conjunction with 67121.
Q. Which modifier should I use when removing silicone oil in the global period? Also, which CPT code is correct – 67036 or 67121?
A. My current choice of modifier for this is -58. CPT describes the uses of the -58 modifier as follows:
► -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.
Removal of the silicone oil is planned prospectively at the time of the insertion and different procedure codes exist for each operation. Most vitreoretinal surgeons agree that removal of the silicone oil is planned prospectively, although that doesn't always happen.
True, it is related to the original procedure; however, the parallelism is that of a Hughes procedure (tarsoconjunctival flap) or Cutler-Beard procedure (full-thickness flap) used in eyelid reconstruction, which is then followed by severing of the reconstructed and donor eyelid areas. In other words, you know prospectively that the oil will be removed.
Two schools of thought currently exist in reference to which CPT code to use. The codes are described in CPT as follows:
► 67036: Vitrectomy, mechanical, pars plana approach
► 67121: Removal of implanted material, posterior segment, intraocular.
I prefer to use 67121 because, from a coder's perspective, it describes the purpose of the procedure – the removal of the implanted material (in this case silicone oil) rather than removal of vitreous, most of which probably is already removed.
This code was developed a long time ago and most likely was for removal of a dropped intraocular lens; but most coders now agree it is a completely appropriate choice for coding removal of silicone oil.
CPT code 67121 is also used for coding other similar situations such as removal of an intravitreal drug implantation system.
CPT codes copyright 2004 American Medical Association
Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at www.RivaLeeAsbell.com.