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  • Savvy Coder

    Coding for Ocular Trauma

    By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement
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    The pandemic’s home improve­ment boom did not go unno­ticed in emergency departments (EDs) around the country. If you need to code for trauma, use the two cases presented as a refresher, and also visit the AAOE’s resources (aao.org/practice-management/coding/coding-ocular-trauma).

    The ED Has Its Own E/M Codes

    E/M codes 99281-99285 are specifically for exams that take place in the ED. If you use these codes, the new stream­lined 2021 E/M documentation guide­lines do not apply. Instead, you must meet the requirements of the 1997 E/M guidelines.

    99285 is the highest level of E/M code in the ED. In both of this month’s cases, there is an immediate threat to vision. This means that you can use E/M code 99285, provided that your documentation shows the following:

    • a chief complaint and a minimum of four elements to the history of the present illness were noted;
    • past, family, and social history were obtained, plus a review of 10 body systems;
    • all 12 exam elements were performed (unless unable to obtain due to the trauma) and exam was done through dilated pupils (unless contraindicated);
    • a mental assessment was noted; and
    • the three components of risk have been met. 

    POS is 23. For an exam in the ED, submit 23 as the place of service (POS) value.

    Case 1: Nail Splinter

    An open globe injury repair requiring removal of cataract without insertion of IOL. A 55-year-old man had been hammering a nail when a piece of the nail’s shaft flew into his left eye.

    Pre-op diagnosis. The pre-op diag­nosis included these elements:

    • Posterior segment intraocular for­eign body
    • Zone 2 globe rupture with uveal prolapse
    • Traumatic cataract
    • Rhegmatogenous retinal detach­ment with 270-degree giant retinal tear

    Title of operation. The patient un­derwent the following procedures:

    • Complex retinal detachment repair with 23-gauge pars plana vitrectomy—CPT code 67113 Repair of complex retinal detachment (e.g., proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens.
    • Repair of zone 2 ruptured globe with resection of uveal tissue, right eye—CPT code 65285 Repair of lacera­tion; cornea and/or sclera, perforating, with reposition or resection of uveal tissue.
    • Posterior segment intraocular (mag­netic) foreign body removal—CPT code 65260 Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or poste­rior route.
    • Pars plana lensectomy—CPT code 66852 Removal of lens material; pars plana approach, with or without vitrec­tomy.

    Coding the case. Follow the nine steps for coding multiple procedures during the same surgical session (see “Take Nine Steps”). This dis­cussion highlights a few of those steps.

    Can you bill for all four procedures? Although you performed four pro­cedures, and each of those has a CPT code, you need to check whether you can bill for all four codes.

    Some procedure codes may be “bundled” together. Bundled codes are pairs of codes that can’t both be billed when performed by the same physician on the same eye on the same day. These pairs are sometimes referred to as CCI or NCCI edits, which is a reference to the National Correct Coding Initiative. If you submit two codes that are bun­dled together, you might be paid only for the one with the lower payment.

    Assess the four codes. You can find out which CPT codes are bundled together by looking at their listings in the AAOE’s Coding Coach (which you can buy at aao.org/coding) or by scrolling through an NCCI spreadsheet (which you can download at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits).

    Coding Coach also lists the number of relative value units (RVUs) that have been assigned to each code. The more RVUs a code has, the higher its reim­bursement rate.

    Here is the key RVU and bundling information:

    • 67113 has 38.26 RVUs and is not bundled with 65285, 65260, or 66852
    • 65285 has 31.42 RVUs and is not bundled with 65260, 66852, or 67113
    • 65260 has 27.52 RVUs and is not bundled with 65285, 66852, or 67113
    • 66852 has 24.18 RVUs and is bun­dled with 67113, but not with 65285 or 65260. (Note: In certain circumstances, 66852 and 67113 can be unbundled.)

    How should you code for surgery? Under the multiple procedure payment rules, payment will be 100% of the allowable for the first procedure that you submit and 50% of the allowable for subsequent procedures. Because 67113 has the highest RVUs, submit it first and submit 65260 and 65285 on the next lines. Don’t submit 66582, as it is bundled with 67113.

    Why bundling matters. If you had disregarded the CCI bundling edits and submitted all four procedure codes, your payment may have been reduced by about $500.

    Don’t forget the modifiers. To indicate that the procedures took place on the left eye, append modifier –LT to all three codes. And since all these procedures have a 90-day global period, you should append modifier –57 to the exam code to indicate to the payer that the exam took place to establish the need for surgery.

    Take Nine Steps

    There are nine steps to follow when coding multiple procedures in the same operative session:

    1. Identify all CPT codes involved, and read their full CPT descriptors.
    2. Comply with the payer’s documentation guidelines, including preauthoriza­tion requirements.
    3. Identify the global period for each CPT code.
    4. List the surgeries in order of highest to lowest allowable for that payer. Payment is 100% of the allowable for the first procedure and 50% for the sec­ond, third, and fourth procedures regardless of whether it is done in the same eye or both eyes.
    5. If applicable, look at the site of service differential.
    6. Look at the CCI or commercial payer edits. Check every combination for edits. If codes are bundled, and it is not appropriate to unbundle them, elimi­nate the lower paying of the two codes.
    7. Append the appropriate modifier(s).
    8. Link the appropriate diagnosis codes.
    9. Submit the claim and check the remittance advice (RA) to confirm that proper payment has been made.

    Case 2: Spring in Eye

    Open globe injury repair requiring reattachment of extraocular muscles and canalicular lid laceration. A 64-year-old man arrived at the ED with a metal spring in his left eye.

    Pre-op diagnosis. The pre-op diag­nosis included these elements:

    • Presumed zone 2/3 ruptured globe with uveal and vitreous prolapse
    • Canalicular laceration repair, left lower lid

    Title of operation. The patient un­derwent the following procedures:

    • Repair of zone 3 open globe injury repair, including removal and reattachment of lateral rectus—CPT code 65285 Repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue and CPT code 67311 Strabismus surgery, recession or resection procedure; 1 horizontal muscle.
    • Injection of intracameral vancomy­cin and ceftazidime—CPT code 66020 Injection, anterior chamber of eye (sep­arate procedure); air or liquid.
    • Canalicular lid laceration—CPT code options: 67930 Suture of recent wound, eyelid, involving lid margin, tarsus and/or palpebral conjunctiva di­rect closure; partial thickness or 67935, which is for the full thickness version of the same procedure.

    Assess the four codes. As in Case 1, you can use Coding Coach to learn if any of the CPT codes are bundled and see how many RVUs each one has:

    • 65285 has 31.42 RVUs and is not bundled with 67311, 67930, 67935, or 66020.
    • 67311 has 16.89 RVUs and is not bundled with 65285, 67930, 67935, or 66020.
    • 67930 and 67935 have 6.78 and 12.52 RVUs, respectively, and are not bundled with 65285, 67311, or 66020.
    • 66020 has 3.70 RVUs. If the patient has Medicare Part B, this code isn’t bundled with 65285, 67311, 67930, or 67935. But, because 66020’s descriptor includes the term separate procedure, most commercial payers will bundle it with all other surgeries, and even with the exam if performed on the same day.

    How should you code for surgery? If you submit 65285–LT as the first procedure on the claim, payment for it will be 100% of the allowable. On subsequent lines, submit 67311–LT and either 67930–LT or 67935–LT (pay­ments will be 50% of the allowable). If the payer is Medicare Part B, you also should submit 66020–LT; however, non-Medicare payers typically have a policy of bundling this injection with all other surgeries.

    Note: Because 65285, 67311, and 67935 are all major surgical procedures, you should append modifier –57 to the appropriate level of exam code. Furthermore, if you also submit 66020 or 67390—which are both defined as minor surgical procedures—you also should append modifier –25 to the exam code.

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    Tip: Check the patient’s insurance. For follow-up appointments outside the global period, make sure you are participating with the patient’s insurance. If not, the patient would end up paying a higher rate—perhaps even all of the costs—and should be notified of this immediately.

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    Acknowledgments: EyeNet thanks Ravi R. Pandit, MD, MPH, Grant A. Justin, MD, and Fasika A. Woreta, MD, MPH, for the two case reports.