Ophthalmology and Optometry Coding Alert

Question:  After discussing the risks and benefits of both cryotherapy and photocoagulation for a retinal detachment repair with the ophthalmologist, the patient preferred photocoagulation. But the ophthalmologist had to discontinue due to the patient’s inability to tolerate the procedure and performed cryotherapy instead. Should I code 67105-53 as well as 67101?

Kentucky Subscriber

Answer: Code only the procedure the ophthalmologist finished (67101, Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, with or without drainage of subretinal fluid), not the one he abandoned (67105, ... photocoagulation, with or without drainage of subretinal fluid). Appending modifier 53 (Discontinued procedure) would not be appropriate in this case.

Opportunity: Your ophthalmologist, however, may be able to append modifier 22 (Unusual procedural services) to the completed procedure to indicate the additional work performed in converting from one procedure to another. The additional work must be significant and documented in the procedure note.

Additional payment would depend upon how much additional work was actually performed and the complications causing the service to be discontinued. Paper claims submitted with documentation to support additional payment would be submitted to the payer. Alternatively, if significant progress had been made prior to discontinuing the initial procedure, you may be able to report it with modifier 53 -- again payment would be dependent upon how much work was performed and documented prior to discontinuation due to the patient well-being.