Coding Q&A

For Medicare coding: Be aware that modifiers rule!


For Medicare Coding: Be Aware That Modifiers Rule!


Whether you are coding surgery, injections, diagnostic tests or office visits, it is imperative to master the use of the proper modifier(s) in order to obtain proper payment or even any payment at all. In the September 2011 column, we covered the use of modifiers 24, 25 and 57. In this review, queries are answered regarding some of the others.

Q. After treating a patient with intravitreal injection of Avastin, followed by focal laser for diabetic macular edema, she did not improve. She is still in the global period but needed treatment with sub-Tenon’s injection of Kenalog as she had not responded. What is the proper modifier?

A. This is problematic, since it is a lesser procedure, was not planned prospectively and is not a diagnostic followed by a therapeutic procedure. Thus, you cannot use modifier 58. It is related to the original procedure, so you cannot use modifier 79. Modifier 78 requires a return to an operating room or dedicated surgical procedure room (not an examination room).

Since this procedure was performed in an examination room, the injection would be considered part of the postoperative management (20% of the global fee is for postoperative management) and cannot be billed.

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Q. We billed an office visit and extended ophthalmoscopy to Medicare. The office visit was paid but the ophthalmoscopy was denied for missing a modifier. What did we miss?

A. The extended ophthalmoscopy (CPT code 92225) simply was not paid because site modifiers were not applied. It is a unilateral test, meaning each eye is coded separately and should always have the RT or LT modifier appended.

Q. One month ago, I performed a pars plana vitrectomy for macular pucker in a patient who had undergone a scleral buckling procedure for repair of a retinal detachment. Unfortunately, he was involved in an auto accident that resulted in displacement of his PC IOL (subluxation into the vitreous cavity but still partially attached to the zonules) as well as a retinal detachment. I performed a pars plana vitrectomy and retrieved the IOL from the posterior segment without inserting a new IOL. Which of the following should I use?

67112: (or perhaps 67108, given that his previous RD surgery was done prior to there being a code 67112)

65920: (or perhaps 67121 as the implanted material is now mostly in the posterior segment)

Modifier: (51 or 59)

A. There are several of issues in this case that merit discussion. First, let’s identify the codes:

67108: (Repair of retinal detachment with vitrectomy, etc.)

67112: (Repair of retinal detachment by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repairs…)

67121: (Removal of implanted material, posterior segment; intraocular)

65920: (Removal of implanted material, anterior segment of eye)

I would code this case as 67108–79 + 67121-51-59-79.

For Medicare, it is to your advantage to use CPT code 67108 rather than 67112, even for recurrent retinal detachment. CPT code 67112 was developed for use with other payers who might not recognize modifiers in a global period and thus reject the claim as being duplicative. By appending modifier 79 to 67108, you are telling Medicare that the procedure is unrelated to the previous procedures performed in the global period.

CPT code 67121 was developed for coding removal of IOLs in the posterior segment, although the code is now used for removal of other implanted material(s) in the posterior segment. CPT code 65920 is not chosen, since the IOL was removed from the vitreous and not the anterior segment. Modifier 59 is used to break the “bundle,” which I believe is justified in this case and, once again, modifier 79 is applied to signify that this procedure is unrelated to the original procedure. RP

All CPT codes copyright 2012 by the American Medical Association.