Ophthalmology and Optometry Coding Alert

Spot the billing error and remedy this CPT^® coding conundrum.

Sometimes your ophthalmologist performs two procedures during one operative session, and that can get you in trouble if you don’t know how to indicate to your payer that you’re billing for two separate, medically necessary procedures.

Procedural coding can be tricky, especially when modifiers are thrown into the mix. Check out the following scenario and see if you would come to the same conclusions regarding how to fix the billing blunder.

Read the Case Scenario

A patient with a history of left cataract removal returns to the office complaining of seeing double, glare, and blurred vision bilaterally, worse on the right. The ophthalmologist notes worsening of the right cataract and cloudiness in the left posterior capsule. They recommend yttrium aluminum garnet (YAG) capsulotomy for left posterior capsule opacity and cataract surgery on the right eye. Your ophthalmologist performed both procedures on the same day for the patient’s convenience because they didn’t want to undergo two separate operative sessions.

You report 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique …  without endoscopic cyclophotocoagulation) for the cataract surgery and 66821 (Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages)) with modifier 79 (Unrelated procedure or service by the same physician … during the postoperative period) for the YAG service but get a denial.

Rectify the Problem

The YAG procedure and cataract surgery are unrelated, and the second procedure was performed within the global period, so it’s understandable why it was tempting to append modifier 79 to the claim. Although modifier 79 may sound appropriate, it is not the correct modifier in this case.

“Modifier 79 applies when a provider performs a surgical procedure during the global period of an unrelated service, not for two services performed simultaneously,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

In this scenario, you should use modifier 59 (Distinct procedural service) or modifier XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure), depending on your payer’s preference, to report the two distinct procedures. Append modifiers LT (Left side) and RT (Right side) for additional clarification.

Follow these four steps to avoid losing money due to improper coding when reporting procedures performed simultaneously.

Step 1: Check NCCI Edits for Bundling

Since your ophthalmologist performed multiple procedures during the same surgical session, your first instinct should be to check for any bundled codes according to the Centers for Medicare & Medicaid Services’ (CMS’) National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits. You’ll find that codes 66821 and 66984 are mutually exclusive.

Step 2: Know How NCCI Edits Work

The NCCI edits are “a national standard for ensuring proper payment and coding. The goal was to set a methodology that would identify unbundling and overcoding scenarios,” according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Know how to interpret NCCI edits: CMS assigns Column 1 status to the comprehensive service and Column 2 status to a code they regard as being a component part of the Column 1 service. Consequently, the code in Column 2 is generally not payable in addition to the first code because its value is accounted for — or bundled — in the payment for the code in Column 1.

CMS then assigns one of three modifier indicators to each edit pair. Here are the indicators and their meanings:

• 0: You cannot unbundle the pair with a modifier; only Column 1 procedures will be paid in claims featuring both services.
• 1: You may report both services together if an NCCI-associated modifier is appended to the Column 2 code and both services are eligible for payment.
• 9: The pair has been deleted and NCCI edits do not apply to this code pair.

This NCCI bundle has an indicator of 1, which means that there is a way to override the edit and permit payment of both procedures. So, your next task is to consider if the circumstances warrant and support separate charges.

Step 3: Recognize When It’s Appropriate to Unbundle Edit Pairs

To separate bundled codes, in addition to being assigned a modifier indicator of 1, the two procedures need to be distinct. When these conditions are met, the payer should provide payment for both. Per CPT^®, “distinct” means performed on a different site or organ system, in a different session, different procedure or surgery, separate incision/excision, or separate lesion/injury. As always, this must be supported by the documentation.

Keep in mind: Use of modifier 59 does not require a separate diagnosis code for each of the services billed. As such, simply using different ICD-10 codes for each of the services performed does not support the use of modifier 59. The codes remain bundled unless the provider can demonstrate the distinct nature of the procedures in the documentation.

Step 4: See if Payer Accepts X{EPSU} modifiers

Check your payer-specific guidelines before submitting the claim, as many are accepting the X{EPSU} modifiers in place of modifier 59 because they provide more detail. For this patient, if their payer is Medicare or a payer that follows Medicare guidelines and recognizes the X{EPSU} modifiers, append modifier XS (Separate structure ...) in place of modifier 59 to indicate the service was distinct because it was performed on a separate organ/structure.

Understand Why 59 Instead of 79 

“CMS’ NCCI edits preclude billing a YAG capsulotomy and cataract removal with an IOL together in most cases. Because the NCCI bundle has an indicator of 1, the codes can be unbundled in certain circumstances using modifier 59 or the appropriate X{EPSU} modifier,” Johnson explains. Since the procedures were done on two different structures, breaking the edit pair with an NCCI-associated modifier would be justified.

This is a prime example of why you should consult the NCCI edits every time you have multiple procedures to determine if the codes are bundled and if it’s possible to unbundle them. These edits are updated quarterly, so be sure to check frequently for updates. 

Note: “The use of modifier 59 to break a payer edit, or unbundle services, on claims for reimbursement gets a fair amount of payer attention. If you use this modifier frequently, you may attract unwanted attention,” Johnson warns. “Before unbundling a published edit, carefully review the patient records to make sure the documentation supports separate payment for each component.”