Coding Q&A

Can I Bill Separately for Anesthesia?

Q. Can the retina surgeon bill CPT code 67500 for retrobulbar anesthesia when performing laser surgery?

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 and physical)

►immediate postoperative care, including dictating operative notes, talking with the family and other physicians

►writing orders

►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 this?

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 billing.

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