Keep Your Practice Up-to-date on 2011 Ophthalmology
Find out what’s been revised, added, and deleted within CPT®s extensive changes.
By Kim M. Ross, OCS, CPC
CPT® 2011 features significant changes to both Category I and Category III codes that eye doctors and their billers ought to know.
Changes in Cornea
Amniotic membrane may be used for ocular surface reconstruction by several methods, at varying levels of physician effort. CPT® represents this hierarchy of services with two new codes and one revised code:
65778 Placement of amniotic membrane on the ocular surface for wound healing; self-retaining
65779 Placement of amniotic membrane on the ocular surface for wound healing; single layer, sutured
65780 Ocular surface reconstruction; amniotic membrane transplantation, multiple layers
These changes have prompted a slew of questions:
Q. What are the global periods and typical allowables for 65778 and 65779?
A. Per the Medicare Physician Fee Schedule (MPFS), 65778 and 65779 carry a 10-day global period (65780 remains at 90 days).
The typical allowable depends on whether you perform the procedure in the office (65778 – $947/65779 – $857) or in a facility (65778 – $57/65779 – $219). The cost of the tissue is built into the practice expense when performed in the office (thus, the higher allowable for office procedures). When the surgery is performed in a facility, the facility must pay for the tissue (a “pass through” for amniotic membrane was revoked).
Q. Can 65778 and 65779 be billed with 65430, 65435, and/or 62780?
A. No. CPT® instructs that neither 65778 nor 65779 should be billed with 65430 Scraping of cornea, diagnostic, for smear and/or culture, 65435 Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage), or 65780.
Q. Which code should we use for tissue glue?
A. CPT® specifies that you should use 66999 Unlisted procedure, anterior segment of eye for placement of amniotic membrane using tissue glue.
Q. A pterygium is removed and, rather than placing an autograft, the physician applies a single sutured layer of amniotic membrane. How should this be coded?
A. In the office, 65779 with the appropriate eye modifier appended should be listed first because it has the highest allowable, followed by 65420 Excision or transposition of pterygium; without graft with modifier 51 Multiple procedure and an appropriate eye modifier appended.
Many payers no longer require modifier 51—check with your payer for specifics.
In an ambulatory surgical center (ASC), submit 65420 first, followed by 65779 with the appropriate eye modifier.
Note: In the office setting, the physician bares the expense of the amniotic tissue and the reimbursement is higher for 65779. When performed in the ASC, the tissue is bundled into the facility payment for the procedure, and 65420 pays higher.
Q. If a pterygium is removed and both an autograft and a single sutured layer of amniotic membrane are used (e.g., for a very large defect), how would this be coded?
A. In the office, use 65779 with an eye modifier and 65426 Excision or transposition of pterygium; with graft with an eye modifier. Payment will be 100 percent of the allowable for the first procedure, and 50 percent of the allowable for the second procedure.
If performed in the ASC, 65426 with an appropriate eye modifier should be submitted first because in this setting 65426 has the higher allowable.
Q. How do we code for the ProKera ring?
A. Report 65778.
Q. If a ProKera® ring is inserted post-operatively within the global period of another cornea procedure, how should the doctor bill?
A. If planned prospectively, use 65778 with modifier 58 Staged or related procedure or service by the same physician during the postoperative period. Payment will be 100 percent of the allowable. You’ll need to begin a new 90-day global period.
If the procedure was not preplanned, submit 65778 with modifier 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period. Payment will be 80 percent of the allowable. Continue the global period of the original procedure.
Q. If laser-assisted in situ keratomileusis (LASIK) is performed and the postoperative ProKera® is for a medical reason, can a claim be submitted using 65778?
A. In the case of a medical complication that results from a noncovered procedure, payment is up to the individual payer’s coverage policy.
Q. If multiple layers of amniotic membrane are used with pterygium surgery, without an autograft, is it appropriate to submit both 65420 and 65780?
A. No. The appropriate code is 65426. This code’s descriptor does not specify the material used, or how many layers are used. CPT® 65780 is for ocular surface reconstruction plus multiple-sutured layers of amniotic membrane. The problem with using 65420 plus 65780 is that the physician would be paid twice for removing the pterygium.
There is no code for multiple-layer amniotic membrane transplantation performed as an add-on procedure; in such a scenario, an unlisted procedure code (e.g., 66999) would be used.
Q. How should we code when a single layer amniotic graft is used with sutures and glue?
A. Report 65779.
Q. How should we code for placement of amniotic membrane, without reconstruction, using self-retaining or single-layer suture technique?
A. For the self-retaining technique, use 65778; for the single-layer suture technique, use 65779.
Q. Which is the proper code for multiple layers of amniograft used for ocular surface reconstruction?
A. Code 65780.
Changes in Glaucoma
CPT® 2011 eliminates two Category III codes for canaloplasty—0176T and 0177T—and adds two new Category I codes (both of which have a 90-day global period when paid under the MPFS):
66174 Transluminal dilation of aqueous outflow canal; without retention of device or stent
66175 Transluminal dilation of aqueous outflow canal; with retention of device or stent
Canaloplasty is an advanced treatment for glaucoma that uses microcatheter technology to enlarge the eye’s natural drainage system (in a manner similar to angioplasty), thereby helping the aqueous fluid drain properly.
New Category III code 0253T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space (Glaukos shunt) was created specifically to address the route of aqueous egress into the suprachoroidal space. This code is listed out of sequence: The entry for 0253T appears between 0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork and 0192T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach.
The MPFS does not include relative value units (RVUs) or values for Category III codes. If Medicare covers the test, payment is at the discretion of the Medicare administrative contractor (MAC), and payments likely will vary. Many MACs have published local coverage determinations (LCDs) for Category III codes. Most non-Medicare carriers consider these emerging technology codes to be “investigational,” and often deny payment.
The descriptor for 66761 Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session) now specifies “per session” rather than “one or more sessions.” In response, the MPFS reduces the global period for this code from 90 days to 10 days.
Codes Eliminated in Retina
Category III codes are reviewed every five years and are eliminated if there is insufficient support for their retention. CPT® 2011 eliminates Category III codes 0016T Destruction of localized lesion of choroid (e.g., choroidal neovascularization), transpupillary thermotherapy and 0017T Destruction of macular drusen, photocoagulation. CPT® now instructs you to use 67299 Unlisted procedure, posterior segment to report these procedures.
Changes in Testing Services
CPT® 2011 eliminates Category III code 0187T and replaces it with 92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral. CPT® also deletes 92135 and replaces it with two new codes:
92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
(Per CPT® instructions, do not report 92133 and 92134 at the same patient encounter.)
What prompted these changes in scanning computerized ophthalmic diagnostic imaging (SCODI) coding? The Centers for Medicare & Medicaid Services (CMS) is charged by law to identify codes with the highest rate of growth and to review these codes to determine if they have been valued properly. The dramatic increase in the number of SCODI procedures being billed each year put 92135 in the crosshairs of CMS. The division into an optic nerve code and a retina code was prompted by the distinctly different uses for the service, and will aid clinicians in reporting different services.
Codes 92312-92134 are bilateral for 2011, and will be reimbursed per test, not per eye (the unilateral designation was discontinued because claims data suggested these procedures were performed bilaterally in the majority of cases). Practices should submit these testing services as a single line item, with no modifiers appended to the service.
New Codes in Telemedicine
Finally, CPT® 2011 adds two new codes to meet the needs of diabetic retinopathy screening programs that provide remote imaging and data submission to a centralized reading center:
92227 Remote imaging for detection of retinal disease (e.g., retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral
92228 Remote imaging for monitoring and management of active retinal disease (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral
Per CPT® instructions, these codes should not be submitted with each other, nor should they be submitted with codes 92002-92014, 92133, 92134, 92250, or with evaluation and management (E/M) of a single organ system—i.e., the eye (99201-99350).
Diabetic retinopathy (DR) is a leading cause of blindness. Early detection makes the condition correctable 95 percent of the time. Imaging retina center technicians easily can look at a photo and read it. The ophthalmologist then can determine if the patient has DR—and if so, the stage of DR and the proper course of treatment.
Equate the term “detection” (new diabetic retinopathy imaging code 92227) with “screening” for diabetic retinopathy. In other words, use 92227 when a diagnosis of DR is not certain and the physician is attempting to confirm the diagnosis. When the patient has active DR that is being managed, use 92228 for the imaging.
Fee Schedule Shake-up is a Wash for Ophthalmology
For 2011, the Physician Fee Schedule conversion factor is 33.9764. This is lower than the 2010 rate, but ophthalmology was granted an increase in practice expense and malpractice values that offset the reduction. Overall, ophthalmology payments should be stable in 2011. Ophthalmology can expect to gain an additional 4 percent by 2013, when improved practice expense values for ophthalmology are fully implemented in the fee schedule.