Laser treatment is a valuable approach for many retinal conditions, including diabetic macular edema, retinal tears and detachments, proliferative retinopathy, and choroidal neovascularization. Correct coding for retinal laser treatments starts with answering these three key questions.
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A single laser treatment can be used in many different procedures and is represented by a variety of CPT codes. The appropriate CPT code to use is based on the patient&#;s diagnosis, not the treatment itself (Table 1).1 For example, if laser treatment is indicated for a retinal detachment, the correct CPT code is . If the same laser procedure is indicated for a retinal tear and prophylaxis of retinal detachment, CPT code is correct.
The next question to answer is whether the laser treatment is considered a major or minor procedure. This is determined by the global period. A major surgery is defined as a procedure with a 90-day global period; a minor surgery has either no global period or a 10-day global period.
Retinal laser therapy can be considered either a major or minor surgery. A crucial step to confirm the correct coding is to note if an examination was performed on the same day. For examinations performed on the same day as a major surgery, append modifier -57, decision for major surgery.
When the laser treatment is a minor surgery, review the documentation for the examination and confirm it meets the definition for modifier -25, or significant, separately identifiable examination the same day as a minor surgery. Consider that, while medically necessary, if the examination was performed to confirm the need for the laser therapy, it is not separately billable. Table 2 is a quick reference guide that provides the Medicare global period for each retinal laser therapy approach and the appropriate modifier to consider for the same-day examination.
Although Medicare Part B has designated global periods for retinal laser therapy codes, other payers may not recognize the same postoperative days. For example, since January , Medicare has assigned a 10-day global period to CPT code (treatment of extensive or progressive retinopathy [eg, diabetic retinopathy], photocoagulation), while some Medicaid plans still recognize CPT code as a major surgery with a 90-day postoperative period.
Another good example is CPT code &#;the global period changed in January to 10 days, but many commercial and other payers have a delayed implementation.
Determining the global period based on the laser code and payer is essential to correct coding. This will help you properly track the postoperative days and know when to bill for office visits. Additionally, for the same-day examination, the correct modifier, -25 or -57, is dependent on the payers&#; global period assignment and the designation of a major or minor surgery.
Developing an internal quick reference guide that outlines the unique payer nuances related to retinal laser therapy codes will assist in appropriate coding of these procedures. For more resources related to retina coding, visit aao.org/retinapm.
If you are considering LASIK, discuss the risks and benefits with your ophthalmologist. Is vision correction surgery the best option for you, or would glasses or contacts be a better choice?
Everyone has their own general and eye health circumstances and lifestyle goals. Discuss these things with your surgeon before going ahead with the surgery. Although LASIK benefits many people, it is not for everyone.
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Will you have a reasonable chance of success and satisfaction with LASIK? Are you willing to accept the unknowns that are part of any medical procedure? Asking the following questions will help you and your ophthalmologist decide together whether LASIK is for you.
The FDA approved LASIK to treat certain degrees of nearsightedness, farsightedness and astigmatism, alone or in combination with near- or farsightedness. In general, severe refractive error reduces the chance of success. It also increases the chance that you will need retreatment.
Vision fluctuates:
Find out if your glasses (or contacts) prescription has stayed about the same.
Give your surgeon a complete list of prescription and over-the-counter medicine you take.
Some conditions that might rule out LASIK or need treatment first include:
Do you need 20/20 vision to do all the things you want to do at work and at play, or would 20/40 be good enough?
Not everyone achieves 20/20 vision with LASIK. Also, there is a chance of side effects and complications from LASIK surgery. Understand these before deciding on LASIK.
Ask about the kinds of adjustments you might need to make during this time.
If you need a retreatment, how might this be different or similar to your first surgery? How about recovery?
It is important to discuss with your surgeon how possible issues might be resolved.
Also, ask what potential related treatments would cost, such as:
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