Ophthalmology and Optometry Coding Alert

Question: A patient had repositioning of the iris and intraocular lens (IOL) and a revision of filtering bleb. One day after surgery, the physician performed an injection of viscoelastic into the anterior chamber. The diagnoses were shallow eye and hypotony. How should I code this?

New Jersey Subscriber  
Answer: Codes 66825 (Repositioning of intraocular lens prosthesis, requiring an incision [separate procedure]) and 66250 (Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure) include the injection, if done in the office, in their global packages. Therefore, unless performed in the operating room (OR) or ambulatory surgical center (ASC), the injection is not billable separately.
 
A flat chamber or shallow eye (360.34, Disorders of the globe; hypotony of eye; flat anterior chamber) means the intraocular pressure drops and the anterior chamber flattens out. The pressure would most likely rise again on its own, but if the ophthalmologist feels the endothelial cells are jeopardized, he or she would perform an injection to raise the pressure and save the cells, which do not regenerate once they are damaged.
 
If the injection, for some reason, were performed in an ASC, the ophthalmologist might bill for it with 66020 (Injection, anterior chamber of eye [separate procedure]; air or liquid) with modifier -78 (Return to the operating room for a related procedure during the postoperative period). (Use 66020 instead of 66030* [ medication] because viscoelastic is a filler, not a medication.) However, the injection procedure requires no draping, prepping or anesthesia, so it is unlikely that it would be medically necessary to perform in an OR. If the viscoelastic agent is not stocked in the office, the physician might take the patient to an ASC or hospital outpatient OR for the procedure.
 
For private payers, if the ophthalmologist performs the procedure in the office, he or she would be able to report 66020-78 because not all insurers follow the same global surgery package guidelines as Medicare.