Article Date: 4/1/2013

Coding Q & A

Unusual Vitreoretinal Surgical Coding Queries


This month we are going to look at some of the unusual cases providers and their staff have queried. Most of you have the coding of routine cases mastered. However, some unusual ones can be a little more difficult.

Q. The surgeon took the patient to the OR to treat an epiretinal membrane. During the procedure the patient developed a retinal detachment. Do I just bill the higher paying repair? Do I need any modifiers?

A. First, this case brings up an important principle of surgical coding: always code what happened by the end of the surgery — not what you intended to happen. The one exception is in keratoplasty coding for which you select the code according to the state of the eye at the beginning of the surgery in terms of phakic, aphakic or pseudophakic.

Thus, this case (assuming the retinal detachment and the epiretinal membrane stripping were performed) would qualify for the repair of complex retinal detachment (vitrectomy plus epiretinal membrane stripping).

Q. I am a little unsure of which modifier to use in this particular case. Our situation is this: We have a patient in the postoperative period for cataract surgery in the right eye; however, we are also treating this patient for wet AMD in the right eye and performing intravitreal anti-VEGF injections in the left eye.

I have been appending modifier 79 to the coding for the intravitreal injections. Sometimes I have to go to second-stage appeal with this and sometimes they do pay. The physician told me that according to what she has read, I need to use modifier 58. Is that correct? I thought you only use 58 when the second procedure is greater than the first? Any help on this will be appreciated.

A. Modifier 58 has three distinct uses and is needed only when the subsequent procedure is performed in the global period of the first procedure. The three uses are: 1) If a lesser procedure (such as a pneumoretinopexy) is followed by a greater procedure (retinal detachment repair by vitrectomy); 2) A staged procedure (planned prospectively or anticipated at the time of the original surgery) such as silicone oil removed in global period; 3) A diagnostic procedure, followed by a definitive procedure (vitreous tap followed by vitrectomy).

Modifier 79 is used for procedures that are unrelated in some way to the procedure performed, specifically, the procedure for which the patient is in the global period.

In this case, the patient’s global period is for cataract surgery in the right eye and the procedure being performed is an intravitreal injection in the left eye. The correct modifier would be 79 because the procedure is not only for a different diagnosis but also in a different eye — totally unrelated to the cataract surgery.

Q. I have a patient who presented with a vitreous hemorrhage and proliferative diabetic retinopathy in the left eye. I performed a vitrectomy with endolaser panretinal photocoagulation (CPT code 67040) in the left eye. He had a subsequent recurrent vitreous hemorrhage. He also needed cataract surgery, which another surgeon performed. The IOL was dislocated in the anterior segment.

During the global period of the first procedure, I repositioned the IOL (scleral fixated the IOL), and also performed a pars plana vitrectomy/epiretinal membrane peeling/endolaser panretinal photocoagulation. How should I code this second surgery?

A. Due to the numerous code edit pairs in the National Correct Coding Initiative there are only two CPT codes one may bill: 67041 (Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker); and 66825 (repositioning of intraocular lens prosthesis, requiring an incision).

However, as always, modifiers control payment for Medicare and you should place modifier 58 (lesser to greater procedure) on the 67041 and modifier 79 on the 66825 (unrelated to any of the previous procedures you performed). In coding alpha-numerical terms: 67041 -58-LT + 66825 – 51-79-LT. RP

Retinal Physician, Volume: 10 , Issue: April 2013, page(s): 61