Article Date: 6/1/2008

Here's Help on 3 Rather Tricky Billing Questions

Here's Help on 3 Rather Tricky Billing Questions


Q. The doctor performed vitrectomy, membranectomy, air-fluid exchange, endo laser, and indirect laser. The diagnoses are: 1) epiretinal membrane, 2) macular edema, 3) branch retinal vein occlusion, 4) retinal hole with local retinal detachment. Would this be 67041 and 67145?

A. The correct coding for this case would be CPT codes 67041 (pars plana vitrectomy with removal of epiretinal cellular membrane (eg, macular pucker) and 67039 (pars plana vitrectomy with focal endolaser photocoagulation). The remaining procedures are bundled, including the external lasers (67145).

Q. Yesterday, a patient had a retinal detachment repaired by scleral buckling, which we coded with CPT code 67107 (repair of retinal detachment with scleral buckle). The patient returned today for a postop visit. The physician did a pneumoretinopexy (CPT code 67110 – SRF (subretinal fluid) had increased from yesterday, tear still elevated superiorly. Should we bill for the 67110? If so, which modifier is appropriate?

A. There are 3 modifiers used to obtain reimbursement for procedures performed in the global period of another procedure. They are: modifiers 58, 78, and 79. One of them must be appended to the subsequent surgery in order to be paid. Each modifier has definitive circumstances for which it is to be used.

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Modifier 58 is used in the following 3 scenarios: 1) when the subsequent procedure is staged (planned prospectively); 2) when a subsequent therapeutic procedure follows a diagnostic procedure; 3) when the subsequent procedure is more extensive than the original procedure. In those instances, a new global period starts and the second surgery is paid at 100% of the allowable.

Modifier 78 is used for procedures related to the original procedure, including surgery for complications. A new global period does not start. The second surgery is paid at the intraoperative value (ie, 70% of the allowable).

Modifier 79 is used when the second surgery is unrelated to the first procedure. A new global period starts. The second surgery is paid at 100% of the allowable.

So, in response to your specific question, the pneumoretinopexy should be billed and would need modifier 78 appended to it since it is related to the original procedure. You will be paid at 70% of the allowable (intraoperative value). A new global period does not start.

However, you can use modifier 78 only if the procedure is performed in an operating or procedure room of a hospital or ASC, an endoscopy suite, or a dedicated laser suite. It cannot be performed in an examining room or in a room that doubles as an examining room. In those settings, it becomes part of the postoperative care for which 20% of the global fee is allocated, and cannot be billed separately.

Q. Which CPT codes should we use for tests using the Optos Panoramic200 technology? We perform both Optos and Optos +.

A. My answer must be somewhat evasive, since it is based on information from unpublished sources.

This test was originally proposed for its own CPT code. It did not receive its own code because it was promoted as a screening test for the most part. However, the test is also being used in conjunction with fluorescein angiography, with the benefit of better visualization in the far periphery compared to standard fundus photographs.

Coding authorities from organized ophthalmology have stated their belief that CPT code 92250 could be used when the Optos was substituting for fundus photography.

Keep in mind that screening examinations are not covered and medical necessity, always the prime requirement for Medicare, must be present for billing the tests.

For non-Medicare insurers, bundling issues may make the question moot in many instances.

CPT codes copyright 2006 American Medical Association. RP

Retinal Physician, Issue: June 2008