Ophthalmology and Optometry Coding Alert

Question: Can I report 67340 for exploratory surgery to rule out an open globe injury? The surgeons detached and then reattached the recti muscles looking for entry wounds. The diagnosis was ocular trauma, and due to the nature of the injury the surgeon felt it necessary to explore for additional sites of injury, laceration or penetration.


Pennsylvania Subscriber


Answer: For the exploration of the globe, report an unlisted-procedure code, 67299 (Unlisted procedure, posterior segment). If the ophthalmologist also performed an orbitotomy (exploration of the orbit), report procedure code 67400 (Orbitotomy without bone flap [frontal or transconjunctival approach]; for exploration, with or without biopsy).

Hidden trap: Stay away from +67340 (Strabismus surgery involving exploration and/or repair of detached extraocular muscle[s] [list separately in addition to code for primary procedure]). Even though it seems to describe some of the surgery the ophthalmologist performed, 67340 is an add-on code. CPT rules specify that you must report 67340 in conjunction with strabismus surgery codes 67311-67334, and you wouldn't report those codes in this scenario.