In a pediatric practice, how long does it take to obtain precertification, preauthorization, or predetermination for benefits? “Forever!” said Traci Fritz, COE, who is executive director of Children’s Eye Care of Michigan, which has 4 clinics in and around Detroit.
Be alert for changes to plans. At Ms. Fritz’s practice, there are approximately 40,000 patient visits per year. Most involve either Medicaid or commercial insurance plans. Both types of plans change so frequently that the practice has this rule: Benefits must be checked at every visit, unless the patient was already seen earlier in the same month.
Staying on top of patients’ benefits is a huge time sink. Ms. Fritz said that each clinic has 1 person assigned to checking benefits and it takes 5 or 6 hours to verify a day’s worth of patients. Plus, on the first day of each month, a supervisor and 2 receptionists arrive 2 hours before clinic so they can review each plans’ benefits to check that nothing significant has changed.
What must be preauthorized? It varies depending on the payer, but exams, tests, and minor and major surgeries may require preauthorization. When you request preauthorization, also ask for the allowable (to ensure the payer has an allowable and that your fee schedule is in alignment with it) and confirm coverage at the planned place of service. Not all payers provide coverage at all facilities.
The movements of each eye are controlled by 6 muscles—some horizontal, some vertical. The CPT codes for surgery depend on which muscles are involved (see “Strabismus Codes,” below).
Example 1. One horizontal muscle in the right eye and another horizontal muscle in the left eye, either report CPT code 67311–50 or, as a 2-line entry, report both 67311–RT and 67311–LT.
Example 2. One vertical muscle in the right eye and another vertical muscle in the left eye, report either CPT code 67314–50 or, as a 2-line entry, both 67314–RT and 67314–LT.
Example 3. Two vertical muscles in the left eye and 1 vertical muscle in the right eye, report, using a 2-line entry, both 67316-LT and 67314-RT.
Requirements vary by payer, but in all 3 examples, payment should be 150% of the allowable.
CPT codes 67311, 67312, 67314, and 67316 are for a strabismus surgery (recession or resection procedure):
- 67311 involves 1 horizontal muscle
- 67312 involves 2 horizontal muscles
- 67314 involves 1 vertical muscle (excluding superior oblique)
- 67316 involves 2 or more vertical muscles (excluding superior oblique).
67343 Release of extensive scar tissue without detaching extraocular muscle (separate procedure)
67345 Chemodenervation of extraocular muscle; also known as Botox.
67346 Biopsy of extraocular muscle
You will also need these 3 modifiers: –LT, for the left eye; –RT, for the right; and –50, if bilateral.
The 6 add-on codes listed below can’t be reported as stand-alone codes; instead, use them in addition to any of the primary procedure muscle codes. Add-on codes are exempt from multiple-procedure payment rules, so payment is 100% of the allowable.
- +67320 Transposition procedure any extraocular muscle
- +67331 Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles
- +67332 Strabismus surgery on patient with scarring of extraocular muscles
- +67334 Strabismus surgery by posterior fixation suture technique
- +67335 Placement of adjustable suture(s) during strabismus surgery, including postop adjustment(s) of suture(s)
- +67340 Exploration and/or repair of detached muscles
Add-On Codes in Action
Example. A patient who had had previous bilateral strabismus surgery returned for bilateral lateral rectus resections. In addition, the surgeon explored the inferior obliques. Here’s how to code for the visit.
- To code for the bilateral lateral rectus resections, report CPT code 67311–50, Strabismus surgery, recession or resection procedure; one horizontal muscle. (Modifier –50 indicates it was performed bilaterally; some payers may prefer 67311–RT and 67311–LT.)
- To code for the “re-op,” use CPT add-on code +67332–50 (some payers may prefer –RT and –LT), Strabismus surgery on patient with scarring of extraocular muscles (e.g., prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (e.g., dysthyroid ophthalmopathy). Operative report should state scar tissue.
- To code for the exploration of the obliques, use CPT add-on code 67340–50, Strabismus surgery involving exploration and/or repair of detached extraocular muscles(s). (Some payers may prefer –RT and –LT, rather than –50.)