Reimbursement Payers

One of the most difficultdilemmas in surgical coding is determiningwhether to bill perextraocular muscle versus

per session, per eyelid versus perside, per lash versus per eyelid perside. Help! Please get your CPT booksout before continuing and pull upMedicare’s Physician Fee ScheduleData Base (MPFSDB) (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html?redirect=/PhysicianFeeSched/).MPFSDB overrules CPT instructionsfor payment for Medicare.

MedicareMPFSDB lists various indicators incategory columns that might be con-sidered funny places. The indicatorsfor diagnostic tests and sides in sur-gery are listed in the column entitled“Bilateral Surgery” and use the fol-lowing system: 0 = Payment adjustment for bilateral

procedures does not apply.Bilateral modifier is inappropriatefor reasons such as (a) physiology;(b) code descriptor specificallystates a unilateral procedure; or (c)procedure is not performed as abilateral procedure.

1 = Payment adjustment applies ifbilled with modifier 50 (paymentbased on billed amount or 150%of the fee schedule amount).(Example: 67810 Biopsy of eyelid)

2 = Payment adjustment does notapply. Payment already based onprocedure being a bilateral proce-

Medicare Surgical Coding forUnilateral, Bilateral—WhateverRiva Lee Asbell

These coding guidelines areoften not well known andtherefore not followed. …Getting paid for a proceduredoes not equate to correctcoding, however, and payerscan ask for their money back.

AE Fall 2012 55

dure. Pays 100% of allowable.(Example: 92250 Fundus photos—there are no surgical procedures)

3 = Usual payment adjustment doesnot apply (primarily radiology pro-cedures). Pays 100% of each side.(Example: 92235 FluoresceinAngiography—there are no surgi-cal procedures)

9 = Concept does not apply.(Example: 65760 Keratomileusis)

In the MPFSDB (also referred toas MFSDB) most ophthalmology sur-gical procedures have an indicator of1; however, there are four codes withindicator 9 and approximately 14codes with indicator 0. Most surgicalcodes have an indicator of 1 becauseit is the most common scenariowhere the same procedure is per-formed multiple times, for example,different eyelids or different sides.Codes 2 and 3 are used mostly fordiagnostic tests. Codes that are nolonger used or where the concept ofbilling for sides does not apply havethe indicator 9.

Codes with a bilateral surgery indicator of “0”The codes with indicator 0 forMedicare include 65756, 66990; thelesion excision codes 67800, 67801,67805, 67808; ocular photodynamictherapy 67221, 67225; the remainder(67320, 67331, 67332, 67334, 67335,67340) are add-on codes. The chalazion excision codes carry thisindicator, thus explaining the impor-tance of selecting the right code. Thecodes are billed per session. Theserules may differ for other insurers.

Strabismus surgery. When coding for strabismus surgery, payattention to these three guidelines.

1. Adjustable sutures. CPT code67335 Placement of adjustablesuture(s) during strabismus surgery,including postoperative adjustment(s) ofsuture(s) was developed for the

adjustment of the sutures; the physician is not really being paid for the insertion of the sutures. CPTAssistant states, “Code 67335 doesnot represent the operating roomperformance of the strabismus sur-gery. Rather it is used to code for theadjustment procedure, regardless ofthe number of adjustable suturesplaced.”1 You may code it once per session but not per eye.

2. Add-on codes. Add-on codesdo not stand alone and must beappended to another code as listedin CPT. They were developed tocompensate surgeons for extra diffi-culty that may be encountered dueto previous surgery, trauma, or vari-ous medical conditions. Previously,they could be coded per side. Thisapplies to codes 67320, 67331,67332, 67334, 67335, and 67340.You may code it once per sessionbut not per eye.

3. Transposition procedure.CPT Assistant states, “A transposi-tion procedure (67320) is performedwhen a patient has lost functioningin one of the extraocular muscles …An add-on code is not used forminor transpositions of a musclecoincident to a recession or resec-tion.”2 Transposition procedures arecoded when the surgical procedureis for correction of a paretic/para-lyzed muscle—not for raising or low-ering the insertions of muscles forcorrection of A or V pattern. Youmay code it once per session butnot per eye.

Codes with a bilateral surgery indicator of “1”Take a look at two specific condi-tions whose coding has bilateral surgery indicator “1.”

Blepharospasm. Chemodener-vation of facial muscles for the correction of blepharospasm iscoded using CPT code 64612

Chemodenervation of muscle(s); mus-cle(s) innervated by facial nerve (e.g.,for blepharospasm, hemifacial spasm).

The code was developed andpriced for the typical patient receiv-ing this procedure per side—not permuscle, nor per number of injec-tions on that side. You may code itper side but not per muscle norper number of injections nor pereyelid.

Trichiasis. One of the most frequently asked questions is “Do Icode for lash removal per lash, pereyelid, or what?” CPT Assistant spec-ifies, “Codes 67820 and 67825 areintended to be reported per proce-dure, not per eyelash or per eyelid.”3

However, for Medicare, the indicatoris 1 so you may bill the code pereyelid but not per lash.

Getting paidThese coding guidelines are oftennot well known and therefore notfollowed. For Medicare, paymentsare calculated by RVUs (relativevalue units) that take into considera-tion the work and expensesinvolved for the typical patient orcase—and that is why the specificexamples we discussed are paid pereye or per side and not per muscleor per injection. Getting paid for aprocedure does not equate to correctcoding, however, and payers can askfor their money back. AE

Notes1. CPT Assistant March 1997 issue, page 52. CPT Assistant April 2001issue, page 13. CPT Assistant July 1998 issue, page 10

CPT codes copyright 2011 American MedicalAssociation

Riva Lee Asbell (954-761-149,RivaLee@RivaLeeAsbell.com)is president, Riva Lee AsbellAssociates, Ft. Lauderdale,Fla.