Ophthalmology and Optometry Coding Alert

Modifier indicator may let you override bundling.

The latest set of Correct Coding Initiative (CCI) edits were effective as of July 1, 2015, and if you missed them, you could be missing new information on what codes you can and cannot report with ectropion and entropion repairs.

In some cases, the ectropion and entropion repair codes appear in Column 1 of the new version, CCI Version 22.1, as comprehensive codes. In other cases, they appear in Column 2, as codes that have been bundled into a Column 1 procedure.

CPT^® code 67961 (Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin) is now bundled into:

• 67917 – Repair of ectropion; extensive (e.g., tarsal strip operations)

• 67924 – Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation).

What it means: Medicare has determined that extensive ectropion and entropion repairs include excision and repair of eyelid. If you report both codes in a bundled pair, Medicare will only reimburse for one.

Example: If you report 67961 and 67917, Medicare will reimburse for 67917, the “comprehensive” or “Column 1” code.

The eyelid excision and repair code 67961 now includes:

• 67916 – Repair of ectropion; excision tarsal wedge

• 67923 – Repair of entropion; excision tarsal wedge.

Both of those codes are also now bundled into the more extensive CPT^® code 67966 (… over one-fourth of lid margin), as were 67917 and 67924.

What it means: In this case, Medicare has determined that 67961 is a more comprehensive procedure than 67916 or 67923, and that 67966 is more comprehensive than 67916, 67917, 67923, or 67924.

Exception: These bundle pairs are marked with modifier indicator “1,” which allows coders to report the codes separately under appropriate clinical circumstances and with the proper modifier attached to the bundled code.

“The only way both codes could be reported together would be for ‘separate site’ – repair of the right eyelid is different than the repair on the left eyelid,” notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “I can’t think of any other situation where both could be reported on the same surgical side/eye.”

Also watch for: CPT^® code 67028 (Intravitreal injection of a pharmacologic agent) is now bundled into:

• 65800 – Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous

• 65810 – … with removal of vitreous and/or discussion of anterior hyaloid membrane, with our without air injection

• 65815 – … with removal of blood, with or without irrigation and/or air injection.

Learn more: For complete information on the Correct Coding Initiative, visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd.