Coding for complex ophthalmic surgeries presents unique challenges that require understanding of fundamental coding and billing principles. From determining the correct CPT and ICD-10 codes to navigating payer-specific guidelines, accuracy is key. Here are five case studies and scenarios to help clarify common coding dilemmas. As you review these scenarios, use the ASC coding and billing checklist to ensure accuracy.1
Case Study 1: Dislocated IOL
Scenario: A patient’s posteriorly dislocated intraocular lens (IOL) in the left eye requires repositioning with scleral fixation. What is the appropriate coding?
Options:
A. CPT code 66986 with ICD-10
code T85.22XA
B. CPT code 66825 with ICD-10
code T85.22XA
C. CPT code 67010 with ICD-10
code T85.22XA
D. CPT code 66984 with ICD-10
code T85.22XA
Answer: B. CPT code 66825 with ICD-10 code H27.132
Discussion: For a dislocated IOL requiring scleral fixation, CPT code 66825 - Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure) is used. The ICD-10 code T85.22XA represents displacement of an intraocular lens, which aligns with the condition described. Remember to always identify the payer, as some payers may not allow any CPT code with the description (separate procedure) if performed with another procedure.
Case Study 2: Removal of Silicone Oil
Scenario: Medicare denied a pars plana vitrectomy removal of silicone oil during the global period of retinal detachment surgery. The ASC claim was submitted as CPT code 67036-78-RT and ICD-10 code T85.39XA. Why was this claim denied?
Options:
A. Incorrect or missing modifier
B. Incorrect or missing CPT code
C. The ICD-10 code is not a covered indication
D. Medicare does not cover surgery in the global period
Answer: C. The ICD-10 code is not a covered indication
Discussion: The ICD-10 code T85.398A is not covered for the CPT code 67036 - Vitrectomy, mechanical, pars plana approach under Medicare’s National Coverage Determination. Access Medicare policies that list covered diagnoses at aao.org/lcds. To be reimbursed appropriately, it is crucial to use a covered diagnosis that aligns with the Medicare guidelines. Report the retinal detachment ICD-10 code as primary, as the reason for removal, with T85.398A secondary.2
Additional payment modifiers are required for physician billing when procedures are performed during a postoperative period. These modifier (-58, -78, -79, e.g.) are not required for ASC billing.3
Case Study 3: Unexpected Refractive Error After Cataract Surgery
Scenario: A patient develops an unexpected refractive error after cataract surgery. What coding should be used for an IOL exchange?
Options:
A. CPT code 66984 with modifier
and ICD-10 code T85.22XA
B. CPT code 66986 with modifier
and ICD-10 code T85.29XA
C. CPT code 66825 with ICD-10
code H27.122
D. CPT code 67036 with ICD-10
code H21.221
Answer: B. CPT code 66986 and ICD-10 code T85.29XA
Discussion: For a variety of reasons, the physician may need to remove an existing IOL and replace it with a new one. Dislocation of the lens, incorrect power, or a problematic lens may be the reason. CPT 66966 is defined as Exchange of intraocular lens. ICD-10 code T85.29XA denotes an other mechanical complication of intraocular lens, initial encounter.
Case Study 4: Intravitreal Injections in ASCs
Scenario: A patient needs an intravitreal injection of Avastin (bevacizumab, Genentech) in the ASC. How should this be billed?
Options:
A. The ASC bills for both drug and procedure. The surgeon does not bill.
B. The ASC bills for both drug and procedure. The surgeon bills both separately.
C. The ASC bills for procedure and drug. The surgeon bills for procedure.
D. The ASC bills for procedure. The surgeon does not bill.
Answer: C. The ASC bills for procedure and drug. The surgeon bills for procedure.
Discussion: In an ASC, the billing process for Avastin injections involves the facility billing and the drug, while the physician bills for just the procedure. Local Coverage Determinations and Local Coverage Articles (LCAs) published by regional Medicare contractors called Medicare Administrative Contractor, or MAC, contain additional information about how to bill for these injections in ASC settings. For example, Noridian, has published an LCA-Article - Billing and Coding: Intraocular Bevacizumab (A53008) which states: For Part B claims, enter “Intravitreal bevacizumab, [dose] mg” in Item 19 of CMS-1500 claim form or in Loop 2300 or 2400, NTE, 02 for electronic claims.4 Following payer guidelines for these procedures are crucial to ensure compliance.
Case Study 5: Natural Lens in Vitreous
Scenario: A patient who had been previously diagnosed with cataracts complains of sudden vision loss and is found to have a spontaneous dislocation of the natural lens into the vitreous. The surgeon performs a pars plana vitrectomy, phacofragmentation, and scleral fixation of a posterior chamber IOL. Which codes should be submitted?
Options:
A. CPT 66984 with ICD-10 H27.131 and H25.091
B. CPT 67036 with ICD-10 H21.221; CPT 66982 with ICD-10 H27.131
C. CPT 66985 with ICD-10 H25.091 and H21.221; CPT 67036 with ICD-10 H27.131
D. CPT 66982 with ICD-10 H25.091 and H21.221; CPT 67036 with ICD-10 H27.131
Answer: D. CPT 66982 with ICD-10 H25.091 and H21.221; CPT 67036 with ICD-10 H27.131
Discussion: In this scenario, the appropriate codes include CPT 66982 for the complex cataract surgery with scleral fixation of the IOL, and CPT 67036 for the preplanned vitrectomy. ICD-10 codes H25.091 and H21.221 should be used to describe the cataract and ciliary body degeneration, while H27.131 represents the posterior dislocation of the lens. These codes are not bundled under National Correct Coding Initiative (NCCI) edits, so they can be billed together.1
Conclusion
Navigating the complexities of ophthalmic coding requires a comprehensive understanding of coding principles and payer guidelines. By carefully reviewing each scenario and ensuring proper use of CPT and ICD-10 codes, as well as adhering to payer-specific rules, you can minimize errors and optimize reimbursement. OASC
References
1. Coding and Compliance | Ophthalmology Management. https://tinyurl.com/29w2wbcd. Accessed August 26, 2024
2. ICD-10 Codes for Removal of Silicone Oil. American Academy of Ophthalmology. https://tinyurl.com/mvmbcjus. Accessed August 20, 2024.
3. ASC Surgical Modifiers Made Easy Ophthalmology Management: Ophthalmic ASC Supplement. https://tinyurl.com/yc38wypx Accessed August 20, 2024.
4. Article - Billing and Coding: Intraocular Bevacizumab (A53008). cms.gov. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=53008&ver=46&bc=0. Accessed August 20, 2024.
