Ophthalmology and Optometry Coding Alert

Question: My ophthalmologist performed an aqueous shunt but added an additional step. Before closing the conjunctiva, she sutured a donor pericardial graft over the tube before closing. Is there an appropriate way to code the extra step taken because it is not listed in the shunt's code description?Virginia SubscriberAnswer: For the aqueous shunt insertion, you should report 66180 (Aqueous shunt to extraocular reservoir [e.g., Molteno, Schocket, Denver-Krupin]).You can, in fact, report an additional code for the graft. Use 67255 (Scleral reinforcement [separate procedure]; with graft). Because the ophthalmologist doesn't have to perform 67255 on every patient who gets a shunt, be sure the documentation includes information about the scleral thinning or other reason for the reinforcement procedure to support medical necessity for the additional procedure.Note: You may need to append modifier 51 (Multiple procedures) to 67255, depending on your carrier, because your physician performed more than one procedure during the same [...]