ANSWERS PROVIDED BY RIVA LEE ASBELL
Q: Are there any stumbling blocks to coding for triamcinolone injections followed by PDT?
A: It is rather easy to code for each of these procedures. The CPT codes are:
67221: destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy (includes intravenous infusion)
67225: photodynamic therapy, second eye, at single session. (List separately in addition to code for primary eye treatment.)
67028: intravitreal injection
of pharmocological agent (separate
All three procedures have a global period of zero days, which means if one of them precedes or follows the other, no modifiers are necessary to engender payment.
However, be cognizant of using drugs off-label for treatment of problems they weren't designed to treat. From a risk management point of view, you should include off-label uses in your informed consent. This is a little-discussed subject, but a Local Coverage Determination from the Kansas Medicare carrier, at www.kansasmedicare.com, makes for interesting reading. The policy is titled "Off-Label Use of Drugs for Nononcological Conditions."
Q: Can you give me some general hints on how to use modifiers for a procedure done in the global period of the first procedure?
A: For Medicare, you must use a modifier in order to be paid for a procedure that is performed within the global period of another procedure. Major surgeries are those defined as having a global period of 90 days. As the surgeon, you should determine which modifier to use, and master these:
-58: This modifier has 3 uses. The first is when you are coding a greater or more extensive procedure that follows a lesser or less extensive procedure in the 90-day global period. When this occurs, append the -58 modifier to obtain payment for the second procedure.
Examples include a vitrectomy (67036) following a vitreous tap (67015); repair of retinal detachment by scleral buckle (67107) or vitrectomy (67108) following pneumatic retinopexy; and vitrectomy with epiretinal membrane repair (67038) following retinal detachment repair by scleral buckle (67107).
The second use of modifier 58 is for procedures that are staged (planned prospectively) such as removal of silicone oil (67121), and photocoagulation following tissue plasminogen activator injection.
The third use is for therapeutic procedures that follow diagnostic procedures, such as a vitreous tap followed by vitrectomy. The use of modifier -58 engenders Medicare payment at 100% of the allowable.
-78: Use this modifier when the second procedure is related to the first procedure, such as a second repair of retinal detachment using a scleral buckle when the first surgery was the same procedure. The Medicare payment in this type of situation is 70% of the allowable.
-79: Use this modifier when the second procedure performed in the global period is unrelated to the first procedure, such as panretinal photocoagulation performed in the second eye during the global period of the same operation performed on the fellow eye. Medicare payment in this type of situation is 100% of the allowable.
In general, if you are "going up the food chain," so to speak, (using more complex procedures and different procedure codes) modifier 58 is the modifier of choice.
If you are using the same procedure code, ie, a repeat procedure using the same technique, then modifier 78 is more appropriate. Modifier 79 is for unrelated procedures and usually you will be operating on a different site or an unrelated condition, and in the latter case the procedure codes will be different.
The use of modifiers 58 and 79 start a new global period whereas use of modifier 78 does not.
Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm in Philadelphia. You can contact her at (215) 629-9221 and
Retinal Physician, Issue: January 2005