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Coding & Reimbursement

CPT 2004:
Know the Codes

By Sue Vicchrilli, COT, OCS, Academy Coding Program Manager,
and Neal Freeman, MD, Academy Health Policy Committee Member
 
 

Following a successful Academy campaign to revise the ophthalmic code set, CPT 2004 includes several new codes. Ophthalmologists should also note modifications to four CPT code descriptions and the elimination of the star (*) indicator for minor procedures.

Five New Surgical CPT Codes
The new surgical codes are covered in the hospital setting and the Academy is working to expand coverage to the ambulatory surgery center. Four of the five surgical codes include coverage for treatment of the following conditions: corneal ulcer, bullous keratopathy, band keratopathy and acute chemical burns.

  • 65780 ocular surface reconstruction; amniotic membrane transplantation. The typical allowable is $766.16. The hospital should bill for the tissue.
  • 65781 limbal stem cell allograft (e.g., cadaveric or living donor). The typical allowable is $1,168.66.
  • 65782 limbal conjunctival autograft (includes obtaining graft). The typical allowable is $1,007.74.
  • 68371 harvesting conjunctival allograft, living donor. The typical allowable is $362.92. Unlike the rule for billing for kidney transplant, in which the recipient’s insurance is billed, this code is to be billed to the donor’s insurance.

To assist in the coding for treatment of conditions such as exposure keratoconjunctivitis and corneal ulcers, CPT has released the following:

  • 67912 correction of lagophthalmos, with implantation of upper eyelid lid load (e.g., gold weight). The typical allowable for this code is $418.93.

This does not include payment for the supply of the gold weight.

Corneal Pachymetry
Since its development, corneal pachymetry has never been separately payable. Instead it is included in the level of exam rendered. The new CPT code

  • 76514 corneal pachymetry, unilateral or bilateral (determination of corneal thickness) is found in the radiology section of CPT. It will require listing the ordering physician’s UPIN number on the HCFA 1500 claim form—the same policy as coding for A-scans. The CPT code has both a technical (–TC) and professional (–26) component and it currently falls under direct supervision, which means a physician of the practice must be on site when the test is performed. The typical allowable is $12.42. The Academy is appealing the low reimbursement.

CPT Description Changes
To simplify insurance coverage, the following code descriptions were changed:

  • 67916 repair of ectropion; blepharoplasty, excision tarsal wedge.
  • 67917 blepharoplasty, extensive (e.g., Kuhnt-Szymanowski or tarsal strip operations).
  • 67923 repair of entropion; blepharoplasty excision tarsal wedge.
  • 67924 blepharoplasty, extensive (e.g., Wheeler operation tarsal strip or capsulopalpebral fascia repairs operation).

Starred Surgical Procedures (*)
Since the inception of CPT, minor procedures that may be payable in addition to the appropriate level of E&M or Eye Code have been identified by a (*) following the CPT code. The problem was that while all starred procedures were minor, not all minor procedures had the (*) indicator. This made coding very difficult.

CPT has eliminated the (*) indicator. Physicians now must identify when a procedure is considered minor, which means the global period is either zero days or 10 days. They must also identify which of those two global periods the procedure has. This information can be found on the CMS Web site (www.cms.gov). It is also in the AAOE’s Minor Surgical Procedures coding module (Product #012041) and the Ophthalmic Coding Coach (#012154), both of which can be ordered at the Academy’s Web site (www.aao.org/store).

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