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Ophthalmology and Optometry Coding Alert

Reader Questions:

Catch Staged Procedure for Post-Op Injections

Published on Fri Jun 10, 2005

Question: A patient who had a trabeculectomy is coming in for 5-FU injections. How should I code the injections if they're occurring within the global period of the surgery?

Massachusetts Subscriber Answer: Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) allows you to report the injection procedure (68200, Subconjunctival injection) within the global of the trabeculectomy (66170, 66172). But for it to be considered "staged," the ophthalmologist must have determined before or during the procedure that the 5-FU injections would be necessary, and indicated this in the patient's medical record or the operative report. For the 5-FU supply, report J9190 (Fluorouracil, 500 mg).
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