The ability to perform surgical procedures is quickly becoming part of the OD’s primary eye care role and, for some, is already second nature.
Mastering the clinical side of surgical procedures is only half of the successful integration into practice; mastering the coding is the other.
Count the Days
Surgical procedures follow their own set of rules, violation of which exposes ODs to the risk of an audit.
The first step to avoiding this is understanding the difference between major and minor surgery, which revolves around the concept of the “global period.” The global period, or global surgical package, is a single payment for all care associated with a surgical procedure. Payment is based on the three phases of a procedure: pre-, intra- and postoperative. The difference between major and minor surgeries is the length (in days) of the global period. Any surgical procedure with a global period of less than 90 days is considered minor surgery. Any surgical procedure with a global period of 90 days is major. The rules differ significantly between the two. Let’s focus on minor surgical procedures here.
Consolidate Your codes
The vast majority of procedures performed on the cornea are minor, either with a zero- or 10-day global period. These include epilation (CPT 67820), corneal foreign body removal (65222), corneal debridement or curettage (65435), placement of amniotic membrane without sutures (65778) and occlusion of the puncta, by plug (68761).
In general, these are the rules surrounding minor surgical procedures:
- There is no pre- or post-op period associated with the code, so the global period is only the date of the surgical procedure itself.
- Unless special circumstances exist, a separate office visit on the same day as the surgery is not billable or payable.
Billing for that office visit is usually the stumbling block for ODs. The minor surgical codes already include an office visit, so the carrier appropriately denies payment for a second office visit on the same day. Many try to work around this by incorrectly using a modifier, thereby putting themselves at even greater risk of being audited for fraud.
The National Correct Coding Initiative (CCI) edits are explicit in addressing this issue and have remove much of the ambiguity with this. Only “a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”1
This policy addresses the use of CPT modifier -25, one of the most abused modifiers as reported by CMS, with a failure rate to meet necessity burden in more than 30% of claims.2
Other CCI edits impact your reporting process when performing multiple procedures on the same day. Consider a patient with a metallic corneal foreign body with a rust ring who requires removal of both and typically would have a bandage contact lens applied. You would think the coding would be: 65222, 65435 and 92071 (fitting of a contact lens for treatment of ocular surface disease).
However, based on the CCI edits, 65222 and 65435 are now bundled together, and you are no longer allowed to bill for the fitting of a bandage lens on the same day as any corneal procedure.1
So, for our clinical example, the coding and billing would be 65222-RT/LT (modifiers used to specify right or left eye and must correspond with laterality specific ICD-10), even if all three procedures are performed.
Incorporating surgical procedures into your practice broadens the depth of care you provide your patients and community. As you hone your clinical skills, make sure your coding skills keep pace to avoid preventable exposure and risk.
Send your coding questions to email@example.com.
1. NCCI Policy Manual 2020.
2. Department of Health & Human Services, Office Of Inspector General. Use of modifier 25. November 2005.