Let’s be honest, none of us decided to become vitreoretinal surgeons for the joys of coding our retinal procedures. However, with recent cuts across the board in surgical, diagnostic, and clinical procedure codes, understanding the nuances of these codes has become a necessity. In this recurring coding blog, I hope to address some of the nuances of recent and upcoming coding changes by the Centers for Medicare & Medicaid Services (CMS).
By now many of you are aware of the 2017 changes to coding for laser (67105) and cryo (67101) for retinal detachment (RD). These included a substantial reduction in reimbursement, but also a change from a 90-day to a 10-day global period. What you may not be aware of are the following subtle implications of these changes.
First off, this has implications on getting paid for the actual clinical exam when performed the same day as treatments. For instance in 2016, in order to get reimbursed for both the exam and treatment, a -57 modifier was applied because laser to RD was considered a major procedure (ie 90-day global). But in 2017 a -25 modifier would need to be used since laser to RD is now considered a minor procedure (ie 10-day global). This error can be particularly costly because most RDs are treated the same day.
Secondly, and perhaps even more confusingly, medical progression from less severe to more severe does not always match up with coding progression. Let me give you a relatively common example – consider the scenario where a retinal tear (RT) is initially treated with laser (67145) or cryo (67141). Despite treatment, if this progresses to a RD that you decide to laser (67105) or cryo (67101) during the 90-day global of the prior treatment what modifier can you use? A -58 modifier was appropriate in 2016 because it applies when going from a lesser procedure to a greater procedure. This made sense medically and in terms of coding. Unfortunately in 2017 that seamless logic no longer applies since from a coding perspective treating a RT is a major procedure and treating a RD is a minor one. Currently a -78 modifier (unplanned treatment during a global period for a related procedure) would apply best, but is only reimbursed 70-80% of the allowed payment.
While understanding these subtleties won’t spare you the stiff neck and backache from a prolonged laser for RD, hopefully this will spare you and your staff the ensuing coding agony.
Ankoor R. Shah, M.D.
Retina Consultants of Houston