DEC 11, 2019
Unbundling Goniosynechialysis with Cataract Surgery
Question: Is it appropriate to unbundle CPT code 65865 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae, with cataract surgery?
Answer: Yes, it may be appropriate to unbundle 65865 with 66984 with modifier -59. The operative report must clearly identify the two separate procedures. Be sure to link each procedure with the correct diagnosis. Often there is supporting documentation in the plan preoperatively. However, the surgeon may need to perform an intraoperative gonioscopy to visualize if the synechialysis is necessary after the cataract removal has been performed.
Learn more about surgeries in the Coding Coach, Glaucoma and Cataract/Anterior Segment Coding Modules.