This issue’s column is devoted to some of the more obscure topics that warrant addressing in ophthalmic surgical coding.

The tips and tricks discussed here will be useful when navigating some of the more challenging aspects of coding. Coding rules are specific to Medicare; however, usually, they are incorporated into other payers’ policies.

THREE BIG QUESTIONS

1. DO I SELECT THE CODE BY WHAT I PLANNED TO DO OR BY WHAT I FINALLY PERFORMED?

Diagnosis and Procedure Codes. For most surgeries, the surgeon should code the procedures that were accomplished and not what was planned originally. When complications or circumstances occur requiring an additional procedure that is not prophylactic, but requires a surgical procedure that differs from the original plan, those procedures are the ones that should be coded.

The diagnoses that are listed on the operative report should be the ones that correlate with the surgical codes that were performed and reported. Extraneous diagnoses that do not support the current procedure are not necessary on the operative note, such as those that start with “…history of.”

The exception is keratoplasty procedures. The Current Procedural Terminology (CPT) code is determined by the state of the eye at the beginning of the procedure and this correlates with the descriptor in the CPT code (phakia, aphakia, pseudophakia).

Example: if a person had prior cataract surgery with implantation of an intraocular lens and is scheduled for a penetrating keratoplasty, then use the CPT code 65755 (corneal transplant, penetrating in pseudophakia).

Purpose of the Procedure. It is essential to code the purpose for which the surgery is being performed (e.g., vitreous hemorrhage removal, retinal detachment repair with vitrectomy, removal of dropped intraocular lens), and not for prophylactic procedures that were also performed. This occurs quite frequently in vitreoretinal surgery, particularly with the use of focal endolaser.

Example: Retinal surgeons often perform endolaser applications at the end of a procedure for prophylaxis. This is not necessarily the purpose of the procedure, and if the focal endolaser applications are prophylactic rather than therapeutic, and an appropriate diagnosis that warrants treatment is not present, then it is best not to code CPT code 67039.

2. WHEN SHOULD I USE THE UNLISTED CODE?

CPT used to give specific instructions that if a given code does not precisely describe what is performed surgically, then an unlisted code must be used. This does not appear in the 2021 CPT book. My personal recommendation is to still abide by this if the procedure descriptor is not very close to what was performed.

Unlisted codes are the ones ending in “99” such as “66999 Unlisted Code Anterior Segment.” These codes should not be used for facility coding because they will not be reimbursed. Medicare contractors have no mechanism in place to have these claims evaluated and assigned a payment value.

For physician reimbursement, the unlisted codes may be utilized; however, caution is warranted. The computer cannot process these claims, and so they are pulled out and given to an individual to determine the pricing for that surgery. Not only does this delay payment, it also may result in a lesser payment than desired. My best advice is if the procedure is minor, do not to bother coding it using an unlisted code, as it may not be worthwhile in the long run.

3. WHEN SHOULD MODIFIER 59 BE USED?

Modifier 59 usage instructions are found in The Medicare National Correct Coding Initiative (NCCI), available online at cms.gov/Medicare/Coding/NationalCorrectCodInitEd , or Google “CMS NCCI.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly and/or excessively.

The CPT Manual defines modifier 59 as follows: “Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

Modifier 59 and other NCCI-associated modifiers should not be used to bypass a PTP (Physician-to-Physician) edit unless the proper criteria for use of the modifier are met.

Many physicians, coders, and billers have not mastered the rules for usage for modifier 59, so it has become a magnetic attraction for an audit. It behooves anyone who is going to append modifier 59 to master the usages and apply it sparingly and with great thought.

BONUS…MISCELLANEOUS TIPS

• Add-on codes. Add-on codes were previously discussed in depth in the August 2021 issue of The Ophthalmic ASC, and I recommend studying that article. Failing to take advantage of them when you can results in lost revenue.
• 66850 vs. 68852 in retina procedures when lens fragments are removed from the posterior segment. This is one of the most frequent areas of misunderstanding in retina coding, and I have written about it extensively. Suffice it to say that it must be mastered by the retina surgeon, and the key points are as follows:
  ▶ The CPT code instruction states use of CPT code 66850 for associated lensectomy even though you are working in the posterior segment. It does not mention lens fragments.
  ▶ The instruction for using the code is a parenthetical remark in CPT that is included after the vitrectomy codes “For associated lensectomy, use 66850.” This is confusing because 66850 is an anterior approach code.
  ▶ It seems more logical to choose 66852 due to the words “pars plana” in the description. However, for Medicare, the claim will not be paid because, under the NCCI, 66852 is bundled with all vitrectomy and retinal detachment repair codes.
• Modifiers for reduced services and discontinued procedures.
  ▶ Medicare’s usage of modifiers for discontinued procedures performed in an ASC are 73 versus 74; the difference being modifier 73 is used when the procedure is cancelled before the administration of anesthesia and modifier 74 is used when the surgery is discontinued after the administration of anesthesia.
  ▶ Note that modifiers 52 and 53 are not used for ASC coding; however, they are used for physician coding. Modifier 52 is used for reduced services when no anesthesia is administered, and modifier 53 is used when anesthesia is used. CPT and Medicare definitions and usages vary from each other and should be studied carefully. Medicare MACs may also vary in reference to input of information. ■

CPT codes copyrighted 2020 American Medical Association.