Determine ‘planned or unplanned’ before separately coding vitrectomy.
With several possible surgical treatments for cataract procedures, which you probably code more often than any other surgery, there’s a lot of room for error – with over $890 at stake for complex cataract procedures in 2009.
Use these tricky scenarios as a guide through some of the most problematic cataract coding situations:
Document Necessity for Planned Vitrectomy
Scenario: During the course of a cataract removal, the vitreous collapses and the ophthalmologist finds it necessary to perform a vitrectomy.
Problem: Can you code separately for the vitrectomy?
Read more to learn solution …
Solution: The answer depends on whether the vitreous collapse was an iatrogenic (inadvertently introduced) complication. Ophthalmologists often have to perform a vitrectomy during cataract surgery due to vitreous collapse in the course of removing a dense, senile cataract. In these cases, Medicare considers the vitrectomy a component of the cataract surgery, and thus not separately payable.
The National Correct Coding Initiative bundles vitrectomy codes 67005 (Removal of vitreous, anterior approach [open sky technique or limbal incision]; partial removal) and 67010 (… subtotal removal with mechanical vitrectomy) into cataract surgery codes 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique, complex …) and 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]), says Riva Lee Asbell, ophthalmic coding and reimbursement educator and principal of Riva Lee Asbell Associates in Ft. Lauderdale, Fla., who led the “Avoid the Modifier Haze” seminar at The Coding Institute’s July conference.
Rationale: “When procedures are performed together that are basically the same, or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is included in the more extensive procedure,” explains Asbell.
Exception: If a prolapsed vitreous exists and is known in advance – and documented in the patient medical record – it is not considered a complication of the cataract surgery. Therefore, the physician who plans to perform a vitrectomy during the same operative session of cataract surgery could code separately for the vitrectomy using modifier 59 (Distinct procedural service): 67005-59 or 67010-59.
Key: Documentation and diagnosis codes can get you reimbursement. Use 379.26 (Vitreous prolapse) for the vitrectomy and the appropriate cataract diagnosis (366.x, Cataract) for the cataract removal.
Be prepared to provide documentation in case you receive denials when using the cataract and vitrectomy codes together, despite using modifier 59. Payers are aware of the potential for abuse of 59 and may want you to go through the review process to prove you’ve met the definition of “distinct procedural service.”
Provide the chart notes to show that you knew about the vitreous collapse in advance and that you made plans to repair it prior to the surgical session of another service. Also, you should provide the operative report with clear documentation showing that there was another condition, besides the cataract surgery, that made the vitrectomy medically necessary.
Want two more scenarios to test your cataract bundling know-how? Go to Supercoder.com, sign up for a 30-day free trial & select ‘ophthalmology’ as your topic area.
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