Ophthalmology and Optometry Coding Alert

Two articles in recent issues of Ophthalmology Coding Alert give conflicting advice on reporting pterygium removals and amniotic membrane transplants.

A Reader Question in the May 2005 issue, "Include Pterygium Removal in Reconstruction," advises to code only the amniotic membrane transplant (65780, Ocular surface reconstruction; amniotic membrane transplantation) when an ophthalmologist performs both the transplant and pterygium excision (65426, Excision or transposition of pterygium; with graft) together.
 
But a Reader Question in the June 2005 issue advises reporting only 65426 when the ophthalmologist performs both procedures.

Our experts agree to report only 65780 when you have to choose only one of those two codes.

Why? CPT code 65780 carries 20.96 relative value units in the Medicare Physician Fee Schedule Database. Code 65426 carries 10.42 RVUs. The two codes are bundled together by the National Correct Coding Initiative - NCCI considers 65780 (the "component code") an intrinsic part of 65426 (the "comprehensive code").
 
However: NCCI has given this bundle a modifier indicator of "1," allowing you to break the bundle and report the two codes together when appropriate by appending a modifier (such as modifier 59, Distinct procedural service).

But "if it is not appropriate to unbundle these two procedure codes, report only 65780," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

Hidden trap: Don't try to report both codes without modifiers. "Medicare will price the claim using the value for the comprehensive code, 65426," the lower paying of the two codes, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

We apologize for the confusion.