I Bill Separately for Anesthesia?
PROVIDED BY RIVA LEE ASBELL
Can the retina surgeon bill CPT code 67500 for retrobulbar anesthesia when performing
A. No. CPT codes 67500 (Retrobulbar injection; medication) and
67505 (Retrobulbar injection, alcohol) are codes for those specific uses and are
not to be used for providing anesthesia.
Under ordinary circumstances, anesthesia cannot be billed separately
when it is performed by the surgeon, whether it is regional or local. For Medicare,
it is part of the global surgery package.
The National Correct Coding Initiative (NCCI) states, "When a
physician performs a procedure and, incidentally, provides the anesthesia, the anesthesia
for the procedure is not reported. (If the anesthesia is provided by the surgeon,
it is included in the global surgery package)."
CPT provides the following information in its introductory remarks in the section entitled "Surgery Guidelines."
"The services provided by the physician to any patient by their
very nature are variable. The CPT codes that represent a readily identifiable surgical
procedure thereby include, on a procedure-by-procedure basis, a variety of services.
In defining the specific services 'included' in a given CPT surgical code, the following
services are always included in addition to the operation per se:
►local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia
►subsequent to the decision for surgery, 1 related E/M encounter
on the date immediately prior to or on the date of procedure (including history
►immediate postoperative care, including dictating operative
notes, talking with the family and other physicians
►evaluating the patient in the post-anesthesia recovery area
►typical postoperative follow-up care..."
CPT does have a modifier, 47, for those unusual circumstances
when the surgeon actually provides regional or general anesthesia, but this rarely,
if ever, applies to ophthalmology.
Q. We are in a large academic medical center and frequently work
with other ophthalmic subspecialists during the same session. For example, after
a macular translocation procedure, in a secondary surgery, I remove the silicone
oil and the strabismus surgeon does some fancy work to correct the torsional diplopia.
What is the best way to code for these complicated procedures?
A. When you have 2 surgeons with different subspecialties who
are in the same practice operate on the same person on the same day, in order to
optimize reimbursement and get paid for each surgeon, independently use modifier
79 on each procedure code for each surgeon. Each surgeon should be paid 100% of
the allowable for the first procedure and 50% of the allowable for the next 4 procedures.
Q. I see that most of the bundles for vitrectomy/retinal detachment
procedures and cataract procedures have been unbundled except for the lensectomy
and 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without
gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal
fluid, scleral buckling, and/or removal of lens by same technique). Can I unbundle
A. Surgical bundles in the NCCI are broken by using modifier 59.
In this case I would not break the bundle, particularly since the lensectomy is
included in the code descriptor.
Q. Can we unbundle the removal of an IOL when doing a pars
plana vitrectomy with removal of the IOL through the posterior incision? We want
to use both CPT codes 67036 (Pars plana vitrectomy) and 67121 (Removal of implanted
material, posterior segment; intraocular).
A. According to NCCI, the 2 codes are not bundled when you
look at 67036 as the column 1 code, but are bundled when you look at 67121 as the
column 1 code. This demonstrates the importance of checking all codes that you are
The bundle is more for situations like removal of an intravitreal
implant such as Vitrasert, where incidental removal of vitreous occurs. If an intentional
complete vitrectomy was performed, I would feel comfortable using modifier 59 to
break the bundle.
CPT codes copyright 2005 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
Retinal Physician, Issue: July 2006