A Medicare guide to ophthalmic ASC reimbursement

Part 2 of a two-part series on coding and reimbursement in 2010.

Riva Lee Asbell

In this second part of the Medicare guide to ophthalmic ASC reimbursement, we will focus on surgical coding. Part 1 may be found in the Jan. 25 issue of Ocular Surgery News, and the complete guide may be found online at www.OSNSuperSite.com/view.aspx?rid=60000.

National Correct Coding Initiative

The National Correct Coding Initiative (NCCI) is a document that correlates Current Procedural Terminology (CPT) codes that cannot be billed together in order to promote correct coding. It is the objective of the NCCI to aid the Centers for Medicare and Medicaid Services in its goal of decreasing fraud and abuse as well as decreasing the number of overpayments erroneously being made to providers. The NCCI is issued quarterly.

The document essentially lists sets of codes that cannot be used together for various reasons. It is also known as the CCI or “bundling lists.”

NCCI used in ASC coding: Because an ASC bills to Part B of Medicare, the physician NCCI edits are the ones that apply. The list of edits is updated quarterly, and coding personnel need to keep up-to-date on this.

Modifiers

The modifiers published in the CPT appendix entitled “Modifiers approved for ambulatory surgery center (ASC) hospital outpatient use” may be used in facility surgical coding. This differs from those simply entitled “Modifiers.”

The SG modifier is not to be appended, effective with the new system.

Modifier 52 has a special use in Medicare ASC coding that differs from what is published in CPT. It is used for coding reduced services for discontinued radiology procedures and other procedures not requiring anesthesia that are partially reduced or discontinued at the physician’s discretion. In this usage, the payment is 50% of the allowed amount.

Modifiers 73 and 74 are ASC specific modifiers often overlooked.

Modifier 73 is to be used prior to anesthesia administration but not when there is an elective cancellation of the procedure. The surgical or diagnostic procedure may be canceled subsequent to surgical preparation, but before the administration of anesthesia. Payment is at 50% of the allowable amount for the procedure.

Modifier 74 is to be used after the procedure has commenced or after the anesthesia was administrated. Payment is at 100% of the allowable amount for the procedure.

Although modifier 50 appears in the table, it should not be used. The Medicare contractors have issued instructions regarding this. Instead, use a two-line entry with a single unit of service on each line or two units of service on a single line. Use of modifier 50 will result in payment for only one side when bilateral surgery was performed.

Non-covered services

Medicare may consider a procedure a non-covered service when performed in an ASC for several reasons. It may be considered cosmetic, or it may appear on the list of procedures not payable by Medicare in an ASC.

When such a procedure is performed, Medicare pays the physician at the facility practice expense (PE) amount rather than the non-facility PE amount, the facility PE being lower.

Medicare pays neither the physician nor the ASC for facility resources, thus the patient is responsible for the facility fee.

A blepharoplasty procedure may be either cosmetic or functional. When it is a cosmetic procedure, the patient should pay both the physician’s fee and the facility fee.

Procedures that are listed in Addendum EE, which is only found on the Internet and not in the Federal Register, are not eligible for payment by Medicare when performed in an ASC.

The following is a partial list of procedures with ophthalmic implications that will not be reimbursed if performed in an ASC:

• 21385 Repair orbital floor blowout fracture; transantral approach
• 21386 Open treatment of orbital floor fracture; periorbital approach
• 21387 Open treatment of orbital floor fracture; combined approach
• 21395 Open treatment of orbital floor fracture; periorbital approach with bone graft (includes obtaining graft)
• 65273 Repair of laceration; conjunctiva, by mobilization and rearrangement, with hospitalization
• 65760 Keratomileusis
• 65765 Keratophakia
• 65767 Epikeratoplasty
• 65771 Radial keratotomy

Unlisted codes: Unlisted codes are the ones ending in “99” such as “66999 Unlisted code anterior segment.” These codes should not be used for facility coding because they will not be reimbursed. Medicare contractors have no mechanism in place to have these claims evaluated and assigned a payment value.

New CPT codes in 2010

New Category I codes

There were no new Category I codes in the Eye Section in 2010; however, two important ones were issued in 2009:

• 65756 Keratoplasty (Corneal transplant; endothelial)
• +65757 Backbench preparation of corneal endothelial allograft

(Note: There is no fee schedule payment rate for 65757 because it is contractor priced and it is not payable to an ASC.)

New Category III codes

• 0198T Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report
• 0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral

Surgical cases workshop

Case 1. Patient presented with uncontrolled glaucoma in the right eye necessitating a trabeculectomy. There were anterior synechiae present as well as a mature cataract. Surgery consisted of a trabeculectomy along with cataract extraction, lysis of anterior and posterior synechiae, and pupillary stretching as well as insertion of an IOL. Code all procedures.

Diagnosis: 1) 366.10 Cataract, right eye

2) 364.72 Anterior synechiae, right eye

3) 364.89 Uncontrolled glaucoma, right eye

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1, 2	66982 Complex cataract extraction	-RT
2) 3	66170 Trabeculectomy	-51-RT

Tips: The reimbursement for codes in the ASC do not necessarily follow the same pricing as in physician billing. In physician coding, 66170 pays more than 66982. Always list codes with highest-paying procedure code first.

Case 2. Patient had mature cataract and astigmatism in the left eye. Surgery consisting of cataract extraction with insertion of a toric IOL was performed. Surgeon wanted to have the ASC charge the patient for the difference in price between the IOL allowance and the cost of the toric lens. Code all procedures.

Diagnosis: 1) 366.10 Cataract, left eye

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1	66984 Extracapsular cataract extraction with IOL	-LT

Tips: Toric IOLs are considered the same as presbyopia-correcting IOLs. The ASC can bill the patient for any extra charges related to the refractive portion of the surgery because it is not considered a covered service. Be sure to follow Medicare’s rules for billing toric IOLs.

Case 3. The anterior segment surgeon proceeded with a planned cataract extraction in the right eye and during the lens extraction dropped the nucleus into the posterior vitreous. A retina surgeon from a different practice was called in and removed the retained lens fragments by phacofragmentation and performed a pars plana vitrectomy. Code all procedures performed by retina surgeon.

Diagnosis: 1) 998.82

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1	67036 Pars plana vitrectomy	-RT
2) 1	66850 Phacofragmentation of lens	-51-RT

Tips: CPT code 66850 is used rather than 66852 per CPT instructions even though an anterior segment approach is not used by the retina surgeon.

Case 4. Patient had previously undergone surgery consisting of insertion of an aqueous shunt for treatment of uncontrolled glaucoma in the right eye. There was conjunctival erosion over the shunt tube in the right eye. The current surgery consisted of revision of the tube placement, insertion of scleral reinforcement, and conjunctivoplasty using a graft from the inferior fornix. Code all procedures.

Diagnosis: 1) 996.59 Mechanical complication of implant, right eye

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1	68320 Conjunctivoplasty	-RT
2) 1	66185 Aqueous shunt revision	-51-RT
3) 1	67255 Scleral reinforcement with graft	-51-RT

Tips: Since 2008, all supplies with the exception of corneal tissue are bundled into the payment amount.

Case 5. Patient had previous retinal detachment repair that included vitrectomy and insertion of silicone oil in the left eye. No longer in the global period, current surgery consists of pars plana vitrectomy and application of focal endolaser in area of the previous retinectomy, air-fluid exchange, air-gas exchange and removal of the previously inserted silicone oil. Extraction of the dense cataract using trypan blue and insertion of an IOL were also performed. Code all procedures.

Diagnosis:1) 362.9 Unspecified retinal disorder, left eye

2) V45.69 Other states following surgery of the eye and adnexa

3) 366.10 Cataract, left eye

4) 996.59 Mechanical complication of implant or device

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1, 2	67039 Pars plana vitrectomy with focal endolaser photocoagulation	-LT
2) 3	66982 Complex cataract extraction with insertion of intraocular lens	-51-LT
3) 4	67121 Removal of implanted material posterior segment, intraocular	-51-59- LT

Tips: ASC coding must abide by the physicians’ NCCI edits. In this example, modifier 59 was applied because it was felt that the surgery was unrelated to the current procedures and reflected current accepted practice patterns. A more conservative approach would be to code only 67039 and 66982.

Case 6. Patient presented with ptosis involving the right upper eyelid as well as dermatochalasis. There was an ectropion of the left lower eyelid. Surgery consisted of functional blepharoplasty of the right upper eyelid, external approach repair of the ptosis by reattaching the levator aponeurosis to tarsus, and a lateral tarsal strip repair of the ectropion of the left lower eyelid. Code all procedures.

Diagnosis: 1) 374.87 Dermatochalasis, right upper eyelid

2) 374.10 Ectropion, left lower eyelid

3) 374.30 Ptosis, right upper eyelid

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1	15823 Functional blepharoplasty, right upper eyelid	-E3
2) 2	67917 Repair of ectropion, extensive, left lower eyelid	-51-E2

Tips: Be sure to use CPT code 15823 and not 15822 for functional procedures. Make sure the dictated procedure states functional or cosmetic blepharoplasty. Blepharoplasty and ptosis surgeries were bundled in version 15.1 of the NCCI effective April 1, 2009.

Case 7. The patient presented with pseudophakic corneal edema in the right eye secondary to a malpositioned anterior chamber IOL. Surgery consisted of penetrating keratoplasty with replacement of the original IOL with a posterior chamber IOL that was sutured to the sclera. Iris repair with sutures was necessitated by the flaccid iris superiorly. Iridocorneal adhesions were dissected and removed. Lens capsule remnants were removed. Code all procedures.

Diagnosis: 1) 371.20 Corneal edema, right eye

2) 996.53 Mechanical complication of IOL implant, right eye

3) 364.72 Anterior synechiae, right eye

4) 364.75 Pupillary abnormalities, right eye

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1	65755 Penetrating keratoplasty in pseudophakia	-RT
2) 2	66986 Exchange of intraocular lens	-51-RT
3) 3	65870 Severing adhesions, anterior synechiae	-51-LT
4) 4	66682 Suture of iris, ciliary body	-51-RT

Tips: When selecting keratoplasty codes, choose the code that represents the state of the eye at the beginning of the surgery, not at the end.

Case 8. Patient had a cicatricial ectropion of the left lower eyelid with a secondary punctal eversion. Surgery consisted of a lateral tarsal strip procedure (performed laterally), excision of scar tissue medially with placement of a full-thickness skin graft, and punctoplasty of the punctum of the left lower eyelid. Code all procedures.

Diagnoses: 1) 374.14 Cicatricial ectropion left lower eyelid

2) 709.2 Scar tissue, left medial canthus

3) 375.51 Eversion of lacrimal punctum, left lower eyelid

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1	67917 Lateral tarsal strip, left lower eyelid	-E2
2) 2	15260 Full-thickness skin graft, left medial canthus	-51-LT
3) 3	15004 Excision of scar tissue, left medial canthus	-51-LT

Tips: Procedures that do not have a CPT code and generally listed as unlisted procedures codes (those ending with “99”) cannot be coded for Medicare because there is not a mechanism in place to price them.

Case 9. During the revision of an aqueous shunt in the right eye, the tube was accidentally cut and the entire shunt was removed. Two weeks later, another shunt was placed with insertion of reinforcement material. The tube eroded through the conjunctiva, and the current surgery consisted of removal of the aqueous shunt with insertion of reservoir shunt using an internal approach. Code all procedures performed subsequent to the placement of the revision of the first aqueous shunt.

Diagnoses: 1) 365.10 Open angle glaucoma

2) 996.59 Mechanical complication of device

3) V45.69 Status post previous intraocular surgery

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1, 2, 3	66180 Insertion of aqueous shunt	-58-RT
2) 1, 2, 3	67255 Scleral reinforcement with graft	-51-58-RT

Surgery:

Diagnosis codes	Procedure codes	Modifiers
2) 1, 2	0191T Insertion of aqueous drainage device, without extraocular reservoir, internal approach	-51-78-RT
3) 2, 3	67120 Removal of implanted material, anterior segment of eye	-51-78-RT

Tips: Category III codes should be used when available and not the Category I code. In this example, 66180 may have been used previously in the second surgery, but it is no longer applicable because a more specific Category III code has been issued.

Case 10. Patient presented with Fuchs’ corneal dystrophy in the left eye necessitating surgery consisting of Descemet stripping automated endothelial keratoplasty. The physician performed the backbench preparation of the tissue. Code all procedures.

Diagnosis: 1) 371.57 Endothelial corneal dystrophy

Surgery:

Diagnosis codes	Procedure codes	Modifiers
1) 1	65756 Keratoplasty (corneal transplant); endothelial	-LT

Tips: Backbench preparation is physician work only and is paid only to the physician. The amount paid is Medicare contractor priced. An ASC will not be reimbursed for it because it is not listed on the Medicare ASC fee schedule.

Modifiers approved for ASC hospital outpatient use

CPT Level I modifiers

25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Service Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non E/M services, see modifier 59.

27 Multiple outpatient hospital E/M encounters on the same date: For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (eg, hospital emergency department, clinic). Note: This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (eg, hospital emergency department, clinic), see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes.

50 Bilateral procedure: Unless otherwise identified in the listing, bilateral procedures that are performed at the same operative session should be identified by adding the modifier 50 to the appropriate five-digit code.

52 Reduced services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s election. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

58 Staged or related procedure or service by the same physician during the postoperative period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: a) planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating or procedure room (eg, unanticipated clinical condition), see modifier 78.

59 Distinct procedural service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

79 Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

74 Discontinued out-patient/ambulatory surgery center (ASC) procedure after administration of anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

76 Repeat procedure by same physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier 76 to the repeated procedure or service.

77 Repeat procedure by another physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This situation may be reported by adding modifier 77 to the repeated procedure/service.

78 Unplanned return to the operating/procedure room for a related procedure by the same physician following initial procedure for a related procedure during the postoperative period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this subsequent procedure is related to the first, and requires the use of the operating or procedure room, it may be reported by adding the modifier 78 to the related procedure. (For repeat procedures on the same day, see modifier 76.)

79 Unrelated procedure or service by the same physician during the postoperative period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79. (For repeat procedures on the same day, see 76.)

Level II (HCPCS/National) modifiers

(Applicable to ophthalmic surgical coding)

E1: Upper left, eyelid

E2: Lower left, eyelid

E3: Upper right, eyelid

E4: Lower right, eyelid

LT: Left side (used to identify procedures performed on the left side of the body)

RT: Right side (used to identify procedures performed on the right side of the body)

List of principal addenda in final rule

Addendum AA: Final ASC covered surgical procedures including surgical procedures for which payment is packaged

Addendum BB: Final ASC ancillary services integral to covered surgical procedures including surgical procedures for which payment is packaged

Addendum DD1: Final ASC payment indicators

Addendum DD2: Final ASC comment indicators

Addendum E: HCPCS codes that are paid only as inpatient procedures

Note: Addendum EE is found on the Internet only: http://www.cms.hhs.gov/ASCPayment/ASCRN/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=3&sortOrder=descending&itemID=CMS1216691&intNumPerPage=10

List of useful links

CMS Web site for ASCs: http://www.cms.hhs.gov/ASCPayment

National Correct Coding Initiative: http://www.cms.hhs.gov/NationalCorrectCodInitEd

Category III codes: http://www.ama-assn.org/ama/pub/category/3885.html

Addendum E: CMS Web site noted above under “Regulations and Notices”

• Riva Lee Asbell is president of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm, and a clinical assistant professor of surgery (ophthalmology) at the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School at Camden. She can be reached at RivaLee@aol.com; Web site: www.RivaLeeAsbell.com.
• CPT codes, copyright 2010, American Medical Association.