Sometimes coding for surgical cases is not black and white—but rather falls into indefinite categories that are different shades of gray. This paper is based on Medicare coding, rules, and regulations, and I offer what I believe is the best choice in each case scenario.

CASE 1

Crystalline Lens Dropped Into Posterior Segment During Cataract Extraction With Resulting Endophthalmitis

This patient presented for a return visit one day after cataract surgery (phacoemulsification of cataract with insertion of intraocular lens) and the crystalline lens dropped into the posterior segment during the original operation. On the postoperative visit the next day, the surgeon noted the patient had endophthalmitis and immediately referred the patient to a retina specialist. Surgery was scheduled for two days later, at which time the endophthalmitis had become markedly severe.

Surgery was attempted, but due to almost impossible visibility, neither the pars plana vitrectomy (PPV) nor the lensectomy could barely be accomplished. A minimal amount of vitreous was removed and practically none of the crystalline lens was removed.

Comment: The correct answer is A. Additionally, I would probably add modifier 52 for reduced services, because the visibility was so poor hardly any surgery was performed.

Current Procedural Terminology (CPT) instructions state that when performing a cataract extraction in conjunction with a PPV, CPT code 66850 rather than 66852 should be used. CPT code 66652 was originally developed for primary surgery for removal of a cataract.

Lastly, it is generally accepted that if there is no instrument change for performing the lensectomy, that portion is not coded.

CASE 2

IOL Dropped During Cataract Extraction With PPV and Exchange of IOL

This patient presented after cataract surgery with insertion of an intraocular lens, and the lens had dropped into the posterior segment during the original cataract procedure. Surgery consisted of a PPV with removal of the intra-ocular lens by bringing it up to the pupillary plane and then removing from the anterior chamber. Insertion of a secondary intraocular lens was performed from an anterior approach and the IOL was sutured in place.

Comment: The correct answer is B. The difference in reimbursement is significant. In fact, CPT code 67121 was originally developed for removal of an IOL that had dropped into the posterior segment.

(See my column in the May issue in reference to CPT code 67121).

The relative value units (RVU) for each are:

A = 25.64 ($925.33)

B = 25.68 + 21.72 + 19.08 ($2399.23)

C = 25.64 + 19.08 ($1613.92)

Note: In the beginning of each year, it is best to look at the RVUs and your MACs Fee Schedules, as this does change.

CASE 3

Coding for a PPV Performed for Removal of Silicone Oil

This patient presented after previous retinal detachment surgery with insertion of silicone oil, and it was felt that it was safe to remove the silicone oil. A complete PPV had been performed and the case consisted solely of removal of the silicone oil.

Comment: The correct answer is B. The difference in reimbursement is significant. In fact, CPT code 67121 was originally developed for removal of an IOL that had dropped into the posterior segment. (See my column in the May 2020 issue).

This is probably the most gray of the cases, in that there is no specific ICD-10-CM or CPT code either for the diagnosis or the surgical removal of the silicone oil. The vitrectomy had been performed during the previous procedure, so no vitreous was removed. It seems to behoove us that CPT code 67121 should be further clarified to include removal of silicone oil or a new code developed. ■

Errata: The Feb. 2020 column “MIGS 2020—Medicare’s New Compliance and Reimbursement Regulations.” The information in the grid for Hydrus Microstent should be amended to eliminate the following: “Current treatment with ocular hypotensive medication.”