Article

CODING Q&A: Focus on Laser Photocoagulation

Let’s review laser photocoagulation of the posterior segment.

Q. What are the indications for laser photocoagulation treatment of the posterior segment?

A. There are many. Most commonly, this is done for treatment of diabetic retinopathy (focal or panretinal)1,2 and for surrounding retinal holes or tears to prevent retinal detachments.3 Other ophthalmic conditions may benefit from laser photocoagulation as well, such as macular edema (eg, branch or central vein occlusions).

Q. Is posterior segment laser photocoagulation covered by Medicare and other payers?

A. Yes, for the proper indications and when supported by the medical record. Few Medicare Administrative Contractors (MACs) have policies for any of these codes.4

Be sure to check for private payer or Medicare Advantage (MA) coverage guidance before initiating treatment and to determine if prior authorization is required.

Q. What CPT codes describe posterior segment laser photocoagulation?

A. While there are many codes that contain the words “photocoagulation,” here we address only the following codes:

  • 67105 Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation
  • 67145 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; photocoagulation
  • 67210 Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation
  • 67220 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation, 1 or more sessions
  • 67228 Treatment of extensive or progressive retinopathy (eg diabetic retinopathy); photocoagulation
  • 67229 Treatment of extensive or progressive retinopathy, 1 or more sessions, preterm infant (less than 37 weeks gestation at birth); performed from birth up to 1 year of age (eg, retinopathy of prematurity), photocoagulation or cryotherapy

Q. Are these codes bundled with other services?

A. Yes. According to Medicare’s National Correct Coding Initiative (NCCI), which is revised quarterly, there is an extensive list of bundled codes, mainly other retinal procedures. In addition, CPT codes 92225 and 92226 (extended ophthalmoscopy, new and subsequent) are bundled with these surgery codes when performed the same day or in the global for the same eye. Established patient exam codes (eg, 92012-92014 and 99211-99215) are also bundled.

Q. What does Medicare allow for the surgeon for these laser photocoagulation codes?

A. The 2017 national Medicare Physician Fee Schedule allowable amounts are as follows:

Code In office In facility
67105 $301.47 $279.93
67145 $535.10 $506.75
67210 $526.85 $509.26
67220 $542.64 $509.26
67228 $346.33 $312.95
67229 $1,186.48 $1,186.48

These amounts are adjusted by local geographic indices; actual payment amounts will vary.

Q. If we need to repeat laser photocoagulation of the posterior segment, is it billable?

A. Note that most of the codes (except 67105 and 67228) contain the descriptor “one or more sessions,” which means that any treatment with the same code for the same eye within the 90-day global period is not payable for the surgeon. The CPT manual states, “Codes 67208, 67210 … 67220, 67229 … include treatment at one or more sessions that may occur at different encounters. These codes should be reported once during a defined treatment period.

In 2016, 67228 was changed to a global period of 10 days; in 2017, the same change was made to 67105. Consequently, these codes are reclassified as minor procedures, with possible restrictions on billing the same-day eye exam. See our FAQ on Modifier 25 for more information. The “one or more sessions” designation was also removed from the descriptors.5

Q. What does Medicare allow for the facility fee for these procedures?

A. All of the codes in this FAQ are classified into APC 5481. However, due to differences in payment methodology for hospitals and ambulatory surgery centers, the fee schedule amounts vary. Remember that global periods do not exist for facilities — each laser treatment is billed. In 2017, the national Medicare fee schedule amounts are as follows:

Code HOPD ASC
67105 $469.67 $170.83
67145 $469.67 $253.68
67210 $469.67 $253.68
67220 $469.67 $253.68
67228 $469.67 $177.29
67229 $469.67 $253.68

These amounts are modified by local indices, so actual payments will vary. RP

REFERENCES

  1. Laser treatment effective for diabetic retinopathy [news release]. Bethesda, MD: National Eye Institute; April 1, 1976. Available at: https://www.nei.nih.gov/news/pressreleases/drspressrelease .
  2. Clinical alert to ophthalmologists: Early Treatment Diabetic Retinopathy Study (ETDRS). Bethesda, MD: National Eye Institute; October 30, 1989. Available at: https://www.nei.nih.gov/NEWS/clinicalalerts/alert-etdrs .
  3. Preferred practice pattern guidelines. San Francisco: American Academy of Ophthalmology. Available at: https://www.aao.org/guidelines-browse?filter=preferredpracticepatternsguideline
  4. National Government Services, Inc. LCD L33628. Panretinal (Scatter) Photocoagulation. Rev eff. 10/01/2016. Available at: http://go.cms.gov/2k2S6Jf
  5. Corcoran Consulting Group. Reimbursement issues related to modifier 25. Available at: https://www.corcoranccg.com/products/faqs/modifier-25/