This column is presented as a quiz with my commentary and an Insider Tip on each of the five questions. Please email me if you have questions you would like to see addressed in future columns.

CATARACT PROCEDURE: Coding for Suturing of an IOL

1. When can CPT code 66682 (Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (e.g., McCannel suture) be used for suturing of IOLs?

1. Whenever the procedure is performed
2. Only when it is performed as an independent procedure
3. When performed in conjunction with CPT code 66985 [Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal]
4. Only when performed in conjunction with complex cataract surgery (CPT code 66982)
5. When performed in conjunction with CPT code 66825 [Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure)]

Correct answer: C

Commentary

CPT instructions following CPT code 66985 state: “For secondary fixation (separate procedure) use 66682.” Formerly, there was a parenthetical comment after code 66985 in CPT indicating that CPT code 66682 should be used for the suturing of IOLs. The comment/wording has been removed, but the usage remains. I opine that complex suturing with an exchange of IOL (CPT code 66986) also could be additionally coded using CPT code 66682.

Insider Tip

Separate Procedure Designation: The designation of “separate procedure” was the subject of a main symposium during an annual meeting of CPT Advisors at which I represented The American Society of Cataract and Refractive Surgeons/American Society of Ophthalmic Administrators for 10 years. At that symposium, I spoke for removal of the designation, as many of the codes with the designation in ophthalmology were erroneous and hindered correct reimbursement. The representative of the American Academy of Ophthalmology endorsed this position. The final CPT Editorial Panel decision was that if any specialty wanted the separate procedure designation removed, it would have to be proposed, and then could be removed. Unfortunately, that never happened in ophthalmology, so we are stuck with some unnecessary and financially punitive codes having that designation.

OCULOPLASTICS: Coding for an Excisional Biopsy

2. What is the correct coding for performing an excisional biopsy when both the biopsy and excision are performed at the same session and sent for pathological diagnosis?

1. CPT code #67810 Incisional biopsy of eyelid skin including lid margin
2. Code for the biopsy plus the excision
3. Code for the biopsy only
4. Code for the excision only
5. Use a pathology diagnosis

Correct answer: D

Commentary

The following excerpts are taken from the introduction of my February 2019 column on biopsies:

“…In coding, there is no such thing as an excisional biopsy. Say what? In Current Procedural Terminology (CPT), the coding book used by all United States insurers, including Medicare, one can code for the excision or the biopsy. A lesion that is excised and then sent for pathologic diagnosis is an excision of that lesion — not a biopsy.

In ophthalmic coding, different sections of the CPT are used in addition to Eye, most often Integumentary and also Musculoskeletal. Biopsies used in ophthalmic coding draw principally from Eye and Integumentary.”

Insider Tip

I highly recommend you read that article if you are coding for biopsies.

GLAUCOMA: Coding iStent inject procedures

3. How should an iStent inject (Glaukos) procedure be coded when performed in conjunction with an extracapsular cataract extraction with insertion of an IOL (CPT code 66984 or 66982)? Note: +0376 is an add-on code and cannot be used independently. CPT codes available for glaucoma surgery are:

0191T    Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; initial insertion

+0376T    each additional device insertion (List separately in addition to code for primary procedure) (Use +0376T in conjunction with 0191T)

1. CPT codes 66984 + 0191T
2. CPT codes 66984 + 0191T + +0376T
3. CPT codes 66082 + 66999
4. CPT code 66999 + send operative notes
5. CPT code 66999 without operative notes

Correct answer: A

Commentary/Insider Tip

The above CPT coding was developed originally for use with iStent, which is a very different product in that it is one device contained in a single injector. Each iStent placement (if multiple stents are used) requires a separate surgical procedure. The use of the add-on code +0376T is an off-label use. Each iStent insertion is a separate procedure using different injectors, each containing a single device (shunt).

For ASC coding, the devices are packaged (N1) and cannot be billed to either Medicare or the patient. The original FDA approval for iStent was for the initial insertion when performed in conjunction with cataract extraction in patients with mild to moderate primary open-angle glaucoma currently on hypotensive medication. When I was researching my first paper on minimally invasive glaucoma surgery, or MIGS as these procedures are known, I contacted the FDA for verification, and they were quite adamant that the approval for iStent was for the initial insertion of the device only. The add-on code (+0376T), thus, became an off-label use — and remains so.

In comparison, iStent inject is a single injector containing two identical devices. It also must be performed in conjunction with cataract extraction; however, the requirement of the patient being on hypotensive medication is not mentioned. Because both iStent inject devices are contained in a single injector, when the iStent inject procedure is performed — and following CPT protocols in other specialties — the iStent inject surgery should be coded only once, currently by using CPT code 0191T. Separate insertions for each stent are neither required nor performed. Most likely, when evaluated by the CMS Relative Value Update Committee (RUC), the second pushing of a button on the previously inserted injector would not count for very much additional work or intensity. Furthermore, if CPT code +0376T would be coded additionally, it would be considered off-label use. It would not qualify as a separate, second procedure being performed in conjunction with a cataract extraction.

ASCs, Here is the question: How can the facility possibly bill for two iStent inject devices when only one product (device) was purchased?

RETINA: Coding for Removal of Silicone Oil as a Subsequent Procedure

4. What is the correct CPT coding for removal of silicone oil as a subsequent, second procedure after surgery consisting of repair of retinal detachment using a pars plana vitrectomy (CPT code 67036) and insertion of silicone oil? Available CPT codes include:

67036    Vitrectomy, mechanical, pars plana approach;

67121    Removal of implanted material, posterior segment; intraocular

67113    Repair of complex retinal detachment… see CPT descriptor

67299    Unlisted procedure; posterior segment

1. CPT codes 67036
2. CPT code 67299
3. CPT codes 67036 + 67299
4. CPT code 67113
5. CPT code 67121

Correct answer: E

Commentary

When deciding which code to choose, always ask yourself, “What was the purpose of this surgery?” For example, if a case consists of removal of silicone oil in an eye that had previously undergone surgery for a retinal detachment (CPT 67108), that eye has been previously vitrectomized. Even if a minor amount of vitreous remains, it is not the same as the full pars plana vitrectomy that had been previously performed. Thus, the purpose of the removal of the silicone oil is either due to it being a preplanned, staged procedure or a complication involving the prior placement of the silicone oil. Thus, the second surgery should be coded with CPT code 67121.

Insider Tip

Although originally developed for removal of an IOL that had dropped into the posterior vitreous (Trexler Topping, MD, recalled this during a coding webinar some years ago), as surgical techniques advanced, the descriptor (implanted material) could and should be applied to removal of silicone oil.

CORNEA: Coding for Surgically Induced Astigmatism

5. A patient presented with surgically induced astigmatism following previous surgeries consisting of prior trabeculectomy and an insertion of an Express mini shunt was performed. Typically, this procedure isn’t covered for correcting the astigmatism resulting from these surgeries. However, the patient has a surgically induced corneal astigmatism due to the above procedures. Which CPT code can be used to possibly justify this surgery consisting of incisions for correction of the astigmatism?

1. CPT code 65771 (Radial keratotomy)
2. CPT code 65775 (Corneal wedge resection for correction of surgical induced astigmatism)
3. CPT code 65772 (Corneal relaxing incision for correction of surgically induced astigmatism)
4. CPT code 66999 (Unlisted procedure, anterior segment of eye) + send operative notes
5. CPT code 66999 (Unlisted procedure, anterior segment of eye) without operative notes

Correct answer: C

Commentary

Medicare will cover and pay for procedures normally considered cosmetic if they are performed for complications/unwanted results of a previous procedure, as in this case.

Insider Tip

Bonus tip for cornea transplant procedures: Selecting the code by the status of the eye (phakic, aphakic, or pseudophakic) at the beginning — not the end — of the procedure is customary with other surgeries. ■

CPT Codes ©2018 American Medical Association