Coding Q&A

Why retinal physicians tend to misuse CPT code 66852


Why Retinal Physicians Tend to Misuse CPT Code 66852


Q. I came across a 2004 article of yours regarding CPT 66850. I had thought about selecting the 66850 code for the removal of a retained lens with a vitrectomy based solely on the CPT directives, but after consulting a physician, he stated 66852 (with or without vitrectomy) would be more appropriate. The CPT book for 2007-2008 had no other notations. Would your 2004 notation still apply in 2008?

A. Yes. It still applies.

CPT code 66850 (Removal of lens material; phacofragmentation technique (mechanical or ultrasonic), with aspiration) is the one that is to be used when a lensectomy is performed in conjunction with a vitrectomy procedure. This is based on the instruction in the CPT manual. It seems a bit unusual to retinal surgeons because an anterior approach is used and most want to use CPT code 66852 (Removal of lens material; pars plana approach, with or without vitrectomy). But 66852 is not your code!

There is some use for 66852 in coding for pediatric cataract removal. The code was developed for primary cataract extraction using a pars plana approach, wherein incidental vitreous may be removed, but a core or complete vitrectomy is not performed."

Q. Can you provide the appropriate coding scenario for a patient who comes in with a retinal detachment and requires retinal cryopexy that day (cryo and gas), then requires additional laser treatment the next day?

A. In attempting to answer this question I had to call the physician. As it turns out, the scenario was such that the cryotherapy and pneumoretinopexy were performed as preliminary procedures, with full intent of performing definitive repair with pars plana vitrectomy the next day. Additional focal endolaser was performed at the time of the pars plana vitrectomy.

Selecting the codes was not difficult — 67110 (pneumoretinopexy) and 67101 (cryotherapy) for the procedures performed on the first day; 67108 (repair of retinal detachment by vitrectomy, etc; which includes the focal laser due to NCCI bundling) for the subsequent procedure. The most important decision was which modifier to apply — 78 or 58. (The reimbursement for modifier 58 is about 30% higher than for modifier 78.)

The correct modifier in this case is 58, based on the procedures being "staged" — planned prospectively — as well as going from a lesser to greater procedure. Conversely, if procedures are not planned prospectively, or are related, then the correct modifier would be 78.

A similar request for coding was presented by another reader wherein pneumoretinopexy, cryotherapy, and photocoagulation were performed on the first day for repair of retinal detachment. Additional laser treatment was given on the second day. The codes for the first day are 67110 and 67101 (67105 — photocoagulation — is bundled) and for the second day 67105. (The additional laser was not planned prospectively.)

In contrast to the previous case, the correct modifier would be 78 because the additional treatment was related to the original procedure.

Making the correct choice between modifiers 58 and 78 remains the source of many coding errors. Modifier 58 is used when the subsequent procedure performed in the global period is one of these 3: (1) staged/performed prospectively; (2) a more extensive procedure (lesser to greater); (3) a therapeutic procedure that follows a diagnostic procedure.

The food chain analogy serves well in helping make the decision. If you are staying at the same level on the food chain when coding the subsequent procedure, select modifier 78. In other words, the procedure is related to the previous one(s), or is at the same level of intensity as the prior ones(s). If you have planned the procedures prospectively (and documented this) and the procedure is greater in intensity/work than the first one(s), use modifier 58.

CPT codes copyright 2006 American Medical Association. RP

Rival Lee Asbell can be contacted at where the order form for her new book "Tips on Ophthalmic Surgical Coding by Subspecialty" can be found and downloaded under Products/Books.