Ophthalmology and Optometry Coding Alert

Missing this advice could cut $95 from your reimbursement for excisions.

When your ophthalmologist removes lesions from a patient's eyelids, check if the removal involves more than the eyelid's skin -- the added complexity puts you in a different section and boosts your pay.

Dig into your ophthalmologist's procedure documentation to determine which code set you should report.

Turn to 67840 for More-Than-Skin Removal

To report 67840 (Excision of lesion of eyelid [except chalazion] without closure or with simple direct closure), make sure the surgery involves more than the eyelid's skin.

Key words: The procedure might involve lid margin, tarsus, and/or palpebral conjunctiva. The ophthalmologist should indicate these terms in the chart notes when documenting the removal of the lesion.

Example: Your ophthalmologist removes a single lesion from a patient's upper-left eyelid. The excision measures 0.8 cm in diameter and includes the lid margin, which the physician submits for pathologic examination. The pathology report returns a benign neoplasm finding.

You should report 67840 in this case because it is the most appropriate code to accurately describe your ophthalmologist's work. Code 67840's 6.80 relative value units (RVUs) will bring $245.38 into the office, about $95 more than 11441 (4.17 RVUs x 36.0846 conversion factor = $150.47). The pricing for 67840 takes into account the difficulty of working around the eye compared to other body parts.

Keep in mind: Selecting the most appropriate CPT code to describe the physician's work is the driving factor behind your code assignment determination. So you should never base your code selection on reimbursement value.

Pathology, Size Matters for Skin Excisions

When your ophthalmologist performs an eyelid lesion excision that involves mainly the eyelid skin, you should turn to the integumentary lesion excision codes. Look at two details to choose the correct code in this section.

For benign lesions, look at 11440-11446, and for malignant lesions turn to 11640-11646 (Excision,malignant lesion including margins, face, ears, eyelids, nose, lips ...). Because a lesion's nature can be very misleading based only on visual examination, you should always wait for the pathology report before billing the excision. Then select your code based on pathologic findings (benign or malignant) and the lesion(s) size (see page 11 for a complete list of eyelid lesion removal codes and when you should use them).

Tip: Select the appropriate lesion excision size code based on the ophthalmologist's report. "If the physician doesn't measure the lesion before he cuts it out, he's cutting his reimbursement in half," says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates.

Warning: You should not use lesion excision and/or repair codes for skin tags. There are separate codes for skin tag removal (11200-11201).

Watch for Multiple-Lesion Pitfalls

Ophthalmologists won't always excise just one lesion at a time, so you'll face yet another coding challenge when your physician removes multiple lesions. Because 67840 is an excision code, which means you report it by the lid, you can't report it with units -- unlike the integumentary codes.

How it works: If you're reporting 67840 for multiple lesions that are located on both lids, you should report 67840 with modifier 50 (Bilateral procedure) to indicate bilateral excision of lesions, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, director of Best Practices-Network Operations at Mount Sinai Hospital in New York City. But if you're reporting a 11440-11446 code for multiple lesions on either the same or different eyelids, you should report the code for each lesion excised.

Rule 1: Check with your payers to find out which modifiers they require when billing multiple lesion excisions. You will likely need to use either modifier 51 (Multiple procedures) or the eyelid modifiers (E1 for upper left, E2 for lower left, E3 for upper right, and E4 for lower right). Some payers will even want both modifier 51 and the eye modifiers.

Rule 2: You cannot add up the lesions to arrive at a larger size. For example, if your ophthalmologist removes two lesions, both under 0.5 cm in diameter, you cannot code 11441 simply by adding the sizes together. Instead, you should report the procedures on separate lines using 11440 twice with the appropriate modifiers. "Documentation is key in the event of a payer review," cautions Mac. "Physicians should include clear labeled drawings of the location and size of each excised lesion in the medical record in addition to a narrative report," she says.