Ophthalmology and Optometry Coding Alert

Patients with diabetic retinopathy (DR) may require a series of laser treatments, predominantly with 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; photocoagulation), 67228 (Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation [laser or xenon arc]), or, sometimes, both. Reporting these procedures requires attention to the "one or more sessions" verbiage in code definitions as well as the number of postoperative days since the previous treatment, which eye is treated, and the diagnosis.
 
Coders must consider whether the patient has background (362.01, Diabetic retinopathy; background diabetic retinopathy) or proliferative (362.02, proliferative diabetic retinopathy) DR. These two diagnoses yield different sets of medically necessary procedures, in the viewpoint of payers, explains Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. Proliferative diabetic retinopathy almost always requires treatment, while background DR may never.
 
Although background and proliferative DR occur often in both eyes, the treatment is unilateral. Bill the appropriate laser code twice when both eyes require treatment, either on one line (67210-50) or two lines (67210, 67210-51-50; or 67210-RT, 67210-LT), depending on the payer's preference. If treating one eye, list the code once.
 
Note: Modifier -50 Bilateral procedure; modifier -51 Multiple procedures; modifiers -RT Right side and -LT Left side.
Diagnosis Coding
Both diagnoses involve diabetes but describe different manifestations of the disease. The most accurate diagnosis code for 67210 is retinal edema (362.83, Other retinal disorders; retinal edema).
 
If a patient's background DR is exacerbated and a small area of edema develops from leaking vessels, it may need treatment with a laser to seal off the leaking blood vessels. This is the focal laser (67210), done on a grid pattern, in a small focal area with "shots" aimed directly at the site of leakage. The best diagnosis code for focal treatment is retinal edema, not background DR. The edema is being treated, not the diabetes.
 
If a patient has proliferative DR, the leakage is more generalized and the treatment involves many more "shots" of the laser, not aimed at a specific area but spread out over the entire retina. The ophthalmologist may target certain vessels, but the treatment, called panretinal (67228), is more involved than focal treatment. Link 362.02 to it.

Coding the Initial Treatment
The conditions are usually discovered on eye examination, when an ophthalmologist is following a patient for diabetes. The retinopathy is most often first detected by extended ophthalmoscopy (92225-92226), and then fluorescein angiography (92235) further defines the extent of the leakage and which vessels are leaking.
 
For example, a patient comes in for a diabetes checkup. After performing extended ophthalmoscopy and fluorescein angiography, the general ophthalmologist determines [...]