Ophthalmology and Optometry Coding Alert

When a patient has purulent endophthalmitis (360.00) and needs an injection of an antibiotic (67028, intravitreal injection of a pharmacologic agent [separate procedure]) and aspiration of the vitreous (67015, aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach [posterior sclerotomy]), many carriers deny payment for both procedures. These codes are not bundled, according to CCI version 6.3, but there are two other possibilities that could be the reason for the denial.

The separate procedure language in 67028 is a possible reason for the denial, according to Raequell Duran, president of Practice Solutions, a coding and compliance consulting company specializing in ophthalmology based in Santa Barbara, Calif.

In the surgery guidelines under the section on separate procedures, CPT states that some of the procedures or services listed as commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term separate procedure. These codes should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

Under the guidelines, it would be inaccurate to bill 67028 with 67015, Duran explains. In addition, when the CCI was first published, there was a stated intention of not paying for any service in addition to a service with the separate-procedure language. Although this is not a national policy, it may be the reason some carriers are denying payment for both services, Duran says.

Duran recommends that the ophthalmologist send the claim to review, and to appeal if necessary, stating these services should be paid for separately. Always include the reason the services were medically necessary when appealing.