Coding Q&A

Solving some tricky surgical coding dilemmas


Solving Some Tricky Surgical Coding Dilemmas

Information Provided by Riva Lee Asbell

Well-intended but frequently erroneous coding advice permeates the various listservs. Physicians often take advice from their colleagues without really learning the coding/reimbursement rules and non-physicians often do not have the clinical background to make the correct coding decisions.

Please be sure to master:

1. Modifiers 58, 78 and 79 plus 59.
2. National Correct Coding Initiative (NCCI).
3. Global surgery concepts and global fees.
4. Using operative notes for coding complicated cases.
5. Sign up for your Medicare Administrative Contractor's listserv(s).

As always, the answers to the cases that follow pertain only to Medicare.

Q: A panretinal photocoagulation was performed in the office on the right eye for proliferative diabetic retinopathy. During the global period, a vitrectomy with endolaser PRP was performed on the right eye for a vitreous hemorrhage. Would modifier 78 or 79 be used?

A: The vitreous hemorrhage is part of the disease process and is not a complication of the PRP. Therefore, the correct answer is modifier 58 (used as a greater procedure following a lesser procedure) because the vitrectomy is a more extensive procedure than the panretinal photocoagulation. Modifier 78 is used for a related procedure such as a complication and requires a return to the operating/procedure room. Modifier 79 is used for an unrelated procedure.

Q: What code(s) should be billed for epiretinal membrane peeling and a vitrectomy with endolaser PRP?

A: The correct codes are 67040 (Vitrectomy with endolaser panretinal photocoagulation) +67041 (Vitrectomy with preretinal cellular fibrosis). They are bundled under the NCCI. Therefore, the highest-paying CPT code, 67040, should be used. There was no mention of a tractional retinal detachment in the question; therefore, it cannot be presumed to be present. This highlights a dilemma in listserv coding—the lack of operative notes to corroborate code selection.

Q: A retinal detachment was repaired by vitrectomy and scleral buckle; some time later, after cataract surgery, the retina re-detached. Subsequently, a vitrectomy, membranectomy, insertion of silicone oil, air/fluid exchange, endolaser and indirect laser iridectomy were performed. The diagnoses were proliferative vitreoretinopathy, retinal detachment and branch vein occlusion.

A: I have seen this coded as CPT code 67043 (Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation). Thus, CPT code 67043 is used for the surgical excision of CNV and is rarely performed for wet macular degeneration since the advent of intravitreal injection treatment.

The correct coding for this case is 67113 (Repair of complex retinal detachment). If the surgery is performed within the global period of a related surgical procedure then use modifier 58. The complex retinal detachment code is not used for complications and requires both a vitrectomy and membrane peeling.

Q. I have heard from another retina practice that they unbundle surgeries using modifier 59 and receive the same payment for the surgery that they did prior to the codes being bundled. I feel that it is incorrect coding. For example, a vitrectomy with membrane peel, endolaser, and fluid air exchange is performed under practice codes 67041, 67040-59, then 67025-59. I would like to know if we are the only retina practice not unbundling or if it is not allowed.

A. See the second case for the correct coding; however, the truly serious issue is unbundling all the codes to obtain payment and passing on the advice. Yes, it works and you will be paid. You also eventually will be audited, with serious consequences. RP

CPT codes ©2011 American Medical Association

Riva 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.