The cases below require an understanding of CPT, modifiers, Correct Coding Initiative (CCI) edits, payers’ allowed amounts, and payment rules for multiple procedures. At last year’s Coding Camp, more than 250 participants voted on the answer they believed to be correct—but in only one of the three cases did the right answer get the most votes. Can you do better?
Case 1: Retained Lens Fragments
During a postop exam, the surgeon determined that the IOL in the patient’s right eye was decentered, and she was concerned that the patient’s continued inflammation was due to retained lens material. Consequently, she performed a pars plana vitrectomy (CPT code 67036), removed fragments via phaco (66850), and performed nonsutured repositioning of the IOL (66825). Which codes would you use?
a) Submit all three CPT codes appended with modifier –78, indicating an unplanned return to the operating room, and modifier –RT, indicating the right eye
b) CPT codes 67036 and 66850 appended with modifiers –78 and –RT
c) CPT codes 67036 and 66825 appended with modifier –78 and –RT
d CPT code 67036 appended with modifier –78 and –RT
How your peers voted: At the 2012 Coding Camp, c) received 52 percent of the votes, b) 41 percent, a) 7 percent, and d) 4 percent.
Case 2: Avastin Injection for DME
In the postop period of a focal laser treatment for diabetic macular edema, the surgeon performs an intravitreal injection of Avastin in the left operative eye. This is done in the office. Which modifiers should be appended to the injection code?
a) –57–LT, indicating the office visit to determine the need for surgery
b) –58–LT, indicating therapeutic care
c) –78–LT, indicating an unplanned procedure
d) –79–LT, indicating an unrelated procedure
How your peers voted: b) received 34 percent of the votes, c) 33 percent, d) 28 percent, and a) 5 percent.
Case 3: YAG Capsulotomy
For the convenience of the patient, the surgeon performs a YAG capsulotomy on the right eye the same day as cataract surgery on the left eye. What modifier(s) should be appended to the YAG code?
b) –59–RT, indicating a separate procedure
c) –78–RT, indicating a unplanned procedure
d) –79–RT, indicating an unrelated procedure
How your peers voted: d) received 43 percent of the vote, b) 26 percent, a) 25 percent, and c) 5 percent.
Case 1: The correct answer is b). Under CCI, 66825 is bundled in with 66850. Since 66825 has a lower allowable than 66850, it is the latter code that should be submitted for payment.
Case 2: The correct answer is b). Injections given during the global period should be appended with modifier
–58. No modifier is necessary for the HCPCS J code for the drug.
Case 3: The correct answer is b). CPT code 66821 YAG capsulotomy is bundled with code 66984 Cataract extraction with insertion of IOL. To correctly unbundle these two surgeries, modifier –59 must be appended. Modifier –79 or the eye modifier is insufficient.
Coding in New Orleans
In addition to the AAOE’s Annual Meeting program, there will be two intensive halfday meetings on Saturday, Nov. 16: AAOE Conquering ICD-10-CM for Ophthalmology (8-11 a.m.) and AAOE Coding Camp (12:30-3 p.m.). These require separate registration. Learn more at www.aao.org/aaoe2013.