Ophthalmology and Optometry Coding Alert

Question: My ophthalmologist performed a needling procedure during the postoperative period of a trabeculectomy to lower a patient's IOP. Can I bill the needling procedure separately or is it considered included because it falls under the trabeculectomy's global surgical package?


South Carolina Subscriber


Answer: Payers consider most related services that an ophthalmologist performs in the postoperative period to be included in the initial procedure, and therefore not separately billable. But because the ophthalmologist performed this procedure for a complication of the initial procedure, it may be separately billable - it all depends on where the needling procedure was performed.

You can separately report the needling of the bleb, 66250 (Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure), using modifier -78 (Return to the operating room for a related procedure during the postoperative period) but only if the needling of the bleb was performed in an operating-room setting. Hospital operating rooms, ambulatory surgical centers and designated laser procedure suites are all considered operating-room settings by Medicare and most Medicare carriers.

If, however, the needling procedure was performed in a non-operating-room setting - for example, in the office or minor procedure room - the procedure is not separately billable.