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  • Savvy Coder

    Code This, Not That—What to Submit for These Scenarios

    By Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement

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    Some choices are better than others. The scenarios below (plus three more online) show that this is as true in coding as it is elsewhere.

    1. E/M Versus Eye Visit Codes

    A new patient was seen for evaluation of a cataract that was affecting her activities of daily living. BCVA was doc­umented, and the comprehensive exam found a worsening, visually significant cataract. The doctor decided to sched­ule surgery for the next available slot.

    Code this: 99204, which is the level 4 new patient E/M code.

    Not: 92004, which is the comprehen­sive new patient Eye visit code.

    Explanation: Although the doc­umentation supports coding either 99204 or 92004, the average payment for this E/M code is around $17 more than for the Eye visit code. If a cataract surgeon only billed Eye visit codes and performed 750 cases per year, collec­tions would be $12,000 less per year compared with billing the E/M code. Furthermore, some commercial payers have frequency edits for Eye visit codes but not for E/M codes. (Frequency edits limit the number of times that you can bill Eye visit codes in a year.)

    2. Pterygium With Graft

    Pterygium removal with sutured amniot­ic membrane tissue (AMT) placement was performed in a patient’s right eye.

    Code this: 65426–RT Excision or transposition of pterygium; with graft.

    Not: 65420–RT Excision or transpo­sition of pterygium; without graft and 65779–59-RT, Placement of amniotic membrane on the ocular layer; single layer, sutured.

    Explanation: The descriptor for CPT code 65426 does not define the type of graft; therefore, the graft can include either conjunctival or AMT placement. Codes 65420 (without graft) and 65779 (placement of AMT) are bundled to­gether, and it would not be appropriate to use modifier –59 to unbundle them.

    3. Vitrectomy, IOL Exchange

    An operative report documents the procedure as pars plana vitrectomy, removal of a dislocated IOL, and inser­tion of a new IOL into the left eye.

    Code this: 66986–LT and 67036–LT for the IOL exchange and pars plana vitrectomy, respectively.

    Not: 67121–LT Removal of implanted material, posterior segment; intraocular and 67036–59–LT, along with 66985-LT Insertion of IOL prosthesis (secondary implant), not associated with concurrent cataract removal.

    Explanation: CPT code 67121 is bundled with 67036. Because both procedures were performed in the same structure (posterior segment) and same eye, it is not appropriate to unbundle with modifier –59. Additionally, CPT code 66986 represents more accurately the removal and insertion of the IOL.

    Tip: When multiple CPT codes can be billed for the same patient encoun­ter, the order in which you list those codes on CMS-1500 can impact how much you get paid. The first CPT code that you list will be paid at 100% of its allowable, and subsequent codes will be paid at 50% of their allowable. Because the allowable for a CPT code is based, in large part, on the number of Relative Value Units (RVUs) assigned to it, you should list multiple CPT codes based on their RVUs.

    The 50% Multiple Procedure Reduction

    For scenario 3, these tables show the reimbursement if the CPT codes are listed in order of allowable.

    Scenario 3: Vitrectomy and IOL Exchange—Code This
    CPT Code Allowable* Allowable Paid*
    66986 $904.61 $904.61
    67036 $897.34 $448.67
    Total payment $1,353.27
    Scenario 3: Vitrectomy and IOL Exchange—Not This
    CPT Code Allowable* Allowable Paid*
    67121 $903.91 $903.91
    67036-59 $0** $0**
    66985 $776.68 $385.34
    Total payment $1,289.25

    * Allowables vary depending on where you are located; you need to find the allowable that your Medicare Administrative Contractor pays in your location.

    ** It is not appropriate to unbundle 67121 and 67036. If you attempt to do so, the second code that you list will be subject to initial denial or, if paid, subject to payer recoupment. Because CMS would deny this payment, the allowable is $0.

    4. Canaloplasty and Goniotomy

    During the same surgical session, both canaloplasty and goniotomy are per­formed in the patient’s right eye.

    Code this: 66174–RT Transluminal dilation of aqueous outflow canal [e.g., canaloplasty]; without retention of device or stent.

    Not: 65820–RT Goniotomy.

    Explanation: CPT codes 66174 and 65820 are bundled. Although 65820 has been assigned 24.41 RVUs, which is higher than the 18.36 RVUs of 66174, it is not appropriate to bill the gonioto­my code. According to the AMA’s CPT Assistant, only CPT code 66174 should be reported as it represents the service performed, and the incision through the trabecular meshwork is incidental to 66174. (For current coding guidance for canaloplasty and goniotomy, visit

    5. OCT, Optic Nerve, and Posterior Segment

    Both OCT of the optic nerve (CPT code 92133) and posterior segment (92134) are per­formed during the same patient encounter.

    Code this: Submit the code for the one test that contributes most to the treatment plan.

    Not: 92133 and 92134–59.

    Explanation: These two tests, 92133 and 92134, are mutually exclusive—meaning un­der no circumstances should they be unbundled. When two tests are bundled the same day, do not report the CPT code that pays more. Instead, code the test that contributes most to the decision-making process for the problems assessed at the encounter.

    6. Pediatric Social Determinants of Health

    A premature baby presents for a follow-up evaluation of retinopathy of prematurity (ROP). The temporary foster custodian is present for the problem-focused examination. The diagnosis is Zone 1, Stage 1 ROP with progression, and follow-up is needed in one or two weeks. Strict compliance with return visits is crucial for appropriate monitoring and treatment. The physician documents that diagnosis and treatment may be signifi­cantly limited by social determinants of health (SDOH) related to the patient being in foster care and the instability of his permanent custodial care.

    Code this: E/M level 4, 99214.

    Not: E/M level 3, 99213 or Eye visit code, intermediate, 92012.

    Explanation: Although a problem-focused exam was performed and documentation meets the requirements of CPT code 92012, that Eye visit code is not the best code to select. Also, the level 3 E/M code 99213 is not correct as the overall medical decision making is not low. The problem is moderate and the risk of complications is moderate, as the diagnosis or treatment is significantly limited by SDOH. To support a higher-level E/M code, make sure that you report ICD-10 code Z62.21 Child in welfare custody.

    7. Botox Wastage

    A functional Botox injection is performed to treat hemifacial spasm on the right side of the face. The procedure note documents that 25 units were injected and 75 units wasted.

    Code this: 64612–RT chemodenervation of muscle(s); muscles(s) innervated by facial nerve, unilateral, along with J0585, 25 units, and J0585–JW, 75 units.

    Not: 64612–RT and J0585, 100 units.

    Explanation: J0585’s descriptor is Injection, onabotulinumtoxina, 1 unit. Conse­quently, the minimum unit that can be billed is 1 unit. If medication wastage is 1 unit or greater, it must be reported with modifier –JW. If instead you use J0585 without a modifier to report the total units injected and wasted, you could prompt a payer review and denial or postpayment recoupment.

    For more guidance on appropriately coding medications, visit­tice-management/coding/injectable-drugs.