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Young Ophthalmologists
Solving Eight Coding Concerns
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When it comes to CPT codes, it can be confusing at best and downright costly at worst. Here are eight common situations and the (usually) quick solution.

Is there a code for laser suture lysis or is it considered suture removal and therefore not billable?

Suture removal, no matter what the method, is considered an integral part of the exam and not separately billable.

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I performed complex cataract extraction (66982) and had to do an anterior vitrectomy (67005) during the same case. Medicare is stating that these codes are "bundled" and is denying the 67005. In order to bill separately, I need to "unbundle." I have never done that before with 67005.

CPT code 67005 has been bundled with 66982 since July 1, 2001. If the vitrectomy was preplanned and documented as such, then it is appropriate to unbundle with the -59 modifier. 

During a cataract extraction surgery, the capsule was torn and there was vitreous loss. An anterior vitrectomy was performed in the same surgery. How should we code this?

If the vitrectomy was a result of vitreous loss during the case, it would be considered incidental to cataract surgery and is not separately billable.

What CPT code is used when cataract surgery is performed, but no IOL is implanted?

Review CPT series 66840-66940 and select the appropriate code depending on the surgical approach used.

We purchased an Intrector® Portable Vitrectomy Instrument for use in endophthalmitis cases. We're unclear how to bill for this when done in the office. Some say it should be CPT 67036, a full-fledged vitrectomy. Others say CPT 67015, aspiration or release of vitreous, pars plana approach (posterior sclerotomy).

It seems the vendor recommends 67036, but we're not intending to perform this in the OR. This is a limited — not a complete — vitrectomy done in the office. On the other hand, it seems more complicated than a tap and inject.


Would CPT 67036-52 (reduced services) be appropriate? Also, how do we recoup the $250 supply cost for the disposables? And do we use CPT 67028 (injection of pharmacologic agent) or is that bundled? 


The company does suggest 67036, but that is not an office-based code and is inappropriate. There is no non-facility (i.e., office) payment in Medicare. Also, all intravitreal injections are bundled as well as 90 days of postop. The same issues apply to 67015.

Another option is 67025, which does have a non-facility payment, but is 90-day global with bundled injections. For Medicare, it’s unlikely you will be paid for the disposables separately, since there are practice expenses in the current payments for all the above codes.

For billing for complex cataract 66982, would you be able to charge if the patient has been on Flomax or injects Shugarcaine for purpose of stabilizing the iris?


Not necessarily. It is important to note that this CPT code is not necessarily for the diagnosis of floppy-iris syndrome or the use of Shugarcaine intraoperatively. One of the qualifying factors must be present.

The Ophthalmic Coding Coach defines it as follows: A miotic pupil that will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye and that requires the insertion of four iris retractors through four additional incisions, Beehler expansion device, a sector iridectomy with subsequent suture repair of iris sphincter, or sphincterotomies created with scissors. The presence of a disease state that produces lens-support structures that are abnormally weak or absent. This requires the need to support the lens implant with permanent intraocular sutures or, alternately, a capsular support ring may be necessary to allow placement of an intraocular lens.

Pediatric cataract surgery, which may be more difficult intraoperatively because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove, and the need for a primary posterior capsulotomy or capsulorrhexis. Futhermore, there is additional postoperative work associated with pediatric cataract surgery; extraordinary work that may occur during the postoperative period. This is the case with pediatric cases mentioned above and, very rarely, when there is extreme postoperative inflammation and pain.

More recently covered is the mature cataract requiring dye for visualization of capsulorrhexis.

We performed a trabeculectomy with a tube shunt using the Ex-Press® glaucoma filtration device. Should we use the temporary CPT code 0192T as recommended by the company and not use 66170 Fistulization for glaucoma; trabeculectomy ab externo in absence of previous surgery, and 66180 Aqueous shunt to extraocular reservoir (e.g., Molteno, Schocket, Denver-Krupin)?

If an Ex-Press® shunt is placed, you must use the established Cat III code (0192T) vs. a Category I code like 66710 or 66180.

What is the CPT code for temporary keratoprosthesis? I see code 65770, which is for permanent, but not sure if there is a code for temporary and/or is it even billable?

This topic was covered in the cornea coding course during the 2010 Annual Meeting in Chicago. The work involved in a temporary placement is actually more extensive than that of a permanent placement. CPT code 65770 is appropriate for either a permanent or temporary keratoprothesis.

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About the author: This article was adapted from the December 2010 issue of Coding Bulletin. It was originally written by Kim Ross, OCS, CPC, coding specialist for the Academy.

 
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