CODING COANION 2019 Ophthalmology A comprehensive illustrated guide to coding and reimbursement Power up your coding optum360coding.com
Contents Getting Started with Coding Companion...i Resequencing of CPT Codes...i ICD-10-CM...i Detailed Code Information...i Appendix Codes and Descriptions...i CCI Edit Updates...i Evaluation and Management...i Index...i General Guidelines...i Evaluation and Management Services Guidelines...1 Ophthalmology Procedures and Services...2 Evaluation and Management... 2 General Integumentary/Skin... 3 Introduction... 9 Repair... 10 Head...24 Arteries and Veins...36 Extracranial Nerves...39 Eyeball...41 Anterior Segment...59 Posterior Segment... 159 Ocular Adnexa... 190 Conjunctiva... 256 Operating Microscope... 295 Medicine Services... 296 HCPCS... 367 Appendix... 368 Correct Coding Initiative Update 23.3... 381 Index... 43 Coding Companion for Ophthalmology Contents i
Getting Started with Coding Companion Coding Companion for Ophthalmology is designed to be a guide to the specialty procedures classified in the CPT book. It is structured to help coders understand procedures and translate physician narrative into correct CPT codes by combining many clinical resources into one, easy-to-use source book. The book also allows coders to validate the intended code selection by providing an easy-to-understand explanation of the procedure and associated conditions or indications for performing the various procedures. As a result, data quality and reimbursement will be improved by providing code-specific clinical information and helpful tips regarding the coding of procedures. For ease of use, Coding Companion lists the CPT codes in ascending numeric order. Included in the code set are all surgery, radiology, laboratory, medicine, and evaluation and management (E/M) codes pertinent to the specialty. Each CPT code is followed by its official CPT code description. Resequencing of CPT Codes The American Medical Association (AMA) employs a resequenced numbering methodology. According to the AMA, there are instances where a new code is needed within an existing grouping of codes, but an unused code number is not available to keep the range sequential. In the instance where the existing codes were not changed or had only minimal changes, the AMA assigned a code out of numeric sequence with the other related codes being grouped together. The resequenced codes and their descriptions have been placed with their related codes, out of numeric sequence. CPT codes within the Optum360 Coding Companion series display in their resequenced order. Resequenced codes are enclosed in brackets for easy identification. ICD-10-CM Overall, the 10th revision goes into greater clinical detail than did ICD-9-CM and addresses information about previously classified diseases, as well as those diseases discovered since the last revision. Conditions are grouped with general epidemiological purposes and the evaluation of health care in mind. New features have been added, and conditions have been reorganized, although the format and conventions of the classification remain unchanged for the most part. Detailed Code Information One or more columns are dedicated to each procedure or service or to a series of similar procedures/services. Following the specific CPT code and its narrative, is a combination of features. A sample is shown on page ii. The black boxes with numbers in them correspond to the information on the page following the sample. Appendix Codes and Descriptions Some CPT codes are presented in a less comprehensive format in the appendix. The CPT codes appropriate to the specialty are included in the appendix with the official CPT code description. The codes are presented in numeric order, and each code is followed by an easy-to-understand lay description of the procedure. The codes in the appendix are presented in the following order: Category II codes are not published in this book. Refer to the CPT book for code descriptions. CCI Edit Updates The Coding Companion series includes the list of codes from the official Centers for Medicare and Medicaid Services National Correct Coding Policy Manual for Part B Medicare Contractors that are considered to be an integral part of the comprehensive code or mutually exclusive of it and should not be reported separately. The codes in the Correct Coding Initiative (CCI) section are from version 23.3, the most current version available at press time. The CCI edits are located in a section at the back of the book. Optum360 maintains a website to accompany the Coding Companions series and posts updated CCI edits on this website so that current information is available before the next edition. The website address is http://www.optum360coding.com/productupdates/. The 2018 edition password is: SCIALTY18 Please note that you should log in each quarter to ensure you receive the most current updates. An email reminder will also be sent to you to let you know when the updates are available. Evaluation and Management This resource provides documentation guidelines and tables showing evaluation and management (E/M) codes for different levels of care. The components that should be considered when selecting an E/M code are also indicated. Index A comprehensive index is provided for easy access to the codes. The index entries have several axes. A code can be looked up by its procedural name or by the diagnoses commonly associated with it. Codes are also indexed anatomically. For example: 67415 Fine needle aspiration of orbital contents could be found in the index under the following main terms: Aspiration Orbital Contents, 67415 OR Orbital Contents Aspiration, 67415 General Guidelines Providers The AMA advises coders that while a particular service or procedure may be assigned to a specific section, it is not limited to use only by that specialty group (see paragraphs two and three under Instructions for Use of the CPT Codebook on page xii of the CPT Book). Additionally, the procedures and services listed throughout the book are for use by any qualified physician or other qualified health care professional or entity (e.g., hospitals, laboratories, or home health agencies). Keep in mind that there may be other policies or guidance that can affect who may report a specific service. Supplies Some payers may allow physicians to separately report drugs and other supplies when reporting the place of service as office or other nonfacility setting. Drugs and supplies are to be reported by the facility only when performed in a facility setting. Professional and Technical Component Radiology and some pathology codes often have a technical and a professional component. When physicians do not own their own equipment and send their patients to outside testing facilities, they should append modifier 26 to the procedural code to indicate they performed only the professional component. HCPCS Pathology and Laboratory Surgery Medicine Services Radiology Category III Coding Companion for Ophthalmology Getting Started with Coding Companion i
Anterior Segment Explanation Epikeratoplasty The cornea is one of several structures in the eye that contributes to refraction. Altering the shape of the cornea therefore alters visual acuity. The physician retracts the patient's eyelids with an ocular speculum and measures the patient's cornea to select the size of trephine that will be used to excise corneal tissue. The physician punches a circular hole in the cornea of the donor eye using the trephine. The physician removes the disk of corneal tissue and sets it aside. On a lathe, the physician shapes a lens made of two layers from a donor cornea, the stroma and Bowman's membrane. The physician sutures this donor cornea to the surface of the patient's cornea. The resulting change in the corneal curvature alters the refractive properties of the cornea to correct the preexisting refractive error. The speculum is removed. Antibiotic ointment and a pressure patch may be applied. Coding Tips Because the correction of a refractive error is usually not done out of medical necessity, the patient may be responsible for charges. Verify with the insurance carrier for coverage. In cases where patients are aphakic (without lens) and lens implantation is contraindicated, reimbursement may be considered if a cover letter accompanies the claim. This procedure is generally performed with a subconjunctival or retrobulbar injection rather than general anesthesia. Do not report with 92025 for computerized corneal topography. Supplies used when providing this procedure may be reported with the appropriate HCPCS Level II code. Check with the specific payer to determine coverage. ICD-10-CM Diagnostic Codes H18.51 Endothelial corneal dystrophy H18.611 Keratoconus, stable, right eye H18.612 Keratoconus, stable, left eye H18.613 H27.01 H27.02 H27.03 H52.01 H52.02 H52.03 H52.11 H52.12 H52.13 H52.211 H52.212 H52.213 H52.221 H52.222 H52.223 Q12.3 T85.21XA T85.22XA T85.29XA Keratoconus, stable, bilateral Aphakia, right eye Aphakia, left eye Aphakia, bilateral Hypermetropia, right eye Hypermetropia, left eye Hypermetropia, bilateral Myopia, right eye Myopia, left eye Myopia, bilateral Irregular astigmatism, right eye Irregular astigmatism, left eye Irregular astigmatism, bilateral Regular astigmatism, right eye Regular astigmatism, left eye Regular astigmatism, bilateral Congenital aphakia Breakdown (mechanical) of intraocular lens, initial Displacement of intraocular lens, initial Other mechanical complication of intraocular lens, initial AMA: 2016,Feb,12; 2014,Jan,11 Relative Value Units/Medicare Edits Non-Facility RVU Facility RVU FUD Status N * with documentation Terms To Know MUE - Modifiers IOM Reference None cornea. Five-layered, transparent structure that forms the anterior or front part of the sclera of the eye. trephine (cornea). Instrument that removes small disc-shaped buttons of corneal tissue for transplanting. l New s Revised + Add On AMA: CPT Assist [Resequenced] 74 Coding=Companion=for=Ophthalmology
- Explanation Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion with removal of foreign body The physician removes a lesion or a foreign body from the orbit through a subciliary, frontal, or transconjunctival incision. In the subciliary incision, an incision is made in the lower eyelid. In the frontal approach, an incision is made in the lid crease with a further postseptal dissection for removal of a lesion or foreign body in this portion of the orbit. In the transconjunctival approach, the lower lid is everted and an incision is made over the infraorbital rim through the inferior cul-de-sac. In, the lesion is excised. In, the foreign body is removed. In either case, the incision is closed with layered sutures. Coding Tips For orbitotomy by lateral approach with bone flap to remove lesion, see 67420; to remove foreign body, see 67430. Surgical trays, A4550, are not separately reimbursed by Medicare; however, other third-party payers may cover them. Check with the specific payer to determine coverage. ICD-10-CM Diagnostic Codes C41.0 C69.61 C69.62 C79.51 D09.21 D09.22 D16.4 D48.0 Malignant neoplasm of bones of skull and face Malignant neoplasm of right orbit Malignant neoplasm of left orbit Secondary malignant neoplasm of bone Carcinoma in situ of right eye Carcinoma in situ of left eye Benign neoplasm of bones of skull and face Neoplasm of uncertain behavior of bone and articular cartilage D49.2 H05.111 H05.112 H05.113 H05.51 H05.52 H05.53 H05.811 H05.812 H05.813 S05.41XA S05.42XA S05.51XA S05.52XA Neoplasm of unspecified behavior of bone, soft tissue, and skin Granuloma of right orbit Granuloma of left orbit Granuloma of bilateral orbits Retained (old) foreign body following penetrating wound of right orbit Retained (old) foreign body following penetrating wound of left orbit Retained (old) foreign body following penetrating wound of bilateral orbits Cyst of right orbit Cyst of left orbit Cyst of bilateral orbits Penetrating wound of orbit with or without foreign body, right eye, initial Penetrating wound of orbit with or without foreign body, left eye, initial Penetrating wound with foreign body of right eyeball, initial Penetrating wound with foreign body of left eyeball, initial AMA: 2016,Feb,12; 2014,Jan,11 2016,Feb,12; 2014,Jan,11 Relative Value Units/Medicare Edits Non-Facility RVU Facility RVU FUD Status 90 A 90 A * with documentation Terms To Know 10.3 10.24 10.3 10.24 MUE 1(2) 1(2) 51 51 13.17 13.33 13.17 13.33 Modifiers 50 50 62* 80 0.79 0.78 0.79 0.78 24.26 24.35 24.26 24.35 IOM Reference None canthotomy. Horizontal incision at the canthus (junction of upper and lower eyelids) to divide the outer canthus and enlarge lid margin separation. foreign body. Any object or substance found in an organ and tissue that does not belong under normal circumstances. hemangioma. Benign neoplasm arising from vascular tissue or malformations of vascular structures. It is most commonly seen in children and infants as a tumor of newly formed blood vessels due to malformed fetal angioblastic tissues. neurofibroma. Tumor of peripheral nerves caused by abnormal proliferation of Schwann cells. orbitotomy. Opening made into the orbital space for biopsy, abscess drainage, or tumor mass or foreign body removal. Ocular Adnexa Coding=Companion=for=Ophthalmology l New s Revised + Add On AMA: CPT Assist [Resequenced] 205