New vitreoretinal codes represent major change for 2008

A major change in the eye section of the Current Procedural Terminology (CPT) coding manual took place beginning this year, with important implications for physician reimbursement. The "old standby" code, CPT 67038-vitrectomy, mechanical, pars plana approach, with epiretinal membrane stripping-was removed from CPT. It was replaced by three new codes. In addition, a complex retinal detachment repair code was created. Consequently, the nature of reporting of many vitreoretinal procedures has been dramatically altered.

Vitreous surgery has undergone great developments during the past two decades. The indications for vitrectomy have expanded significantly, and techniques have been modified accordingly. Many disparate vitreous cases ended up "lumped" into 67038 when that option was available in the code set.

The vitrectomy code was changed, at least in part, because code 67038 was brought by Centers for Medicare and Medicaid Services to the "5-year review" for consideration of modifying the valuation of that code. The American Medical Association Relative Value System Update Committee determined that it was not possible to arrive at correct valuation with code 67038 as written. Rather, it was recommended that the code be brought to the CPT editorial panel for modification. With the ensuing changes, vitreous surgery once again is described accurately.

New codes

The three new codes that evolved from 67038:

•  67041-Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (e.g., macular pucker).

•  67042-Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (e.g., for repair of macular hole, diabetic macular edema). Includes, if performed, intraocular tamponade (i.e., air, gas, or silicone oil).

•  67043-Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (e.g., choroidal neovascularization). Includes, if performed, intraocular tamponade (i.e., air, gas, or silicone oil) and laser photocoagulation.

The new complex retinal detachment code appears in CPT 2008 as:

•  67113-Repair complex retinal detachment (e.g., proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90º), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens.

The descriptor for the complex retinal detachment code 67113 closely resembles that of CPT 67108. The differences are that the complex retinal detachment code descriptor provides examples of the various scenarios in which 67113 might be indicated, adds membrane peeling, and also includes silicone oil tamponade if utilized. The vignette for 67113 includes a description of a posterior retinotomy. This descriptor is absent from the description of 67108.

The old CPT 67028 carried slightly fewer than 40 total relative value units (RVUs). Valuations of the four new codes range from 30 to 40 RVUs.

Medicare's Correct Coding Initiative bundles the three vitrectomy codes, 67041 through 67043, with 67108, repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique. This is a change from the old 67038, which was payable in addition to 67108. Now, a procedure combining a scleral buckle with pars plana vitrectomy and membrane peeling is reported as 67113 rather than the combination of 67038 and 67108.

As would be expected, code 67108 cannot be billed in addition to 67113, the complex retinal detachment code. Because 67113 lists removal of lens in the descriptor, the cataract extraction codes are bundled into 67113. The three vitrectomy codes (as was the case with the old 67038) may be billed in addition to the cataract extraction codes.

Reimbursement

Private payers are under no obligation to follow Medicare's Correct Coding Initiative. They may choose to bundle the new codes with any of a number of codes, including those from the vitreous, retina, and lens sections of CPT.

All three vitrectomy codes and the complex retinal detachment code are on Medicare's list of approved procedures for ambulatory surgery centers (ASCs). The ASC will receive approximately $1,540 in compensation when any of those procedures is performed. That payment is among the highest that an ASC can receive for any ophthalmic procedure. The reason for the relatively generous payment is that the new codes are "ramped up" to the appropriate percentage of the hospital outpatient rate immediately. Other codes must go through a 4-year transition before reaching the full payment rate.

Medicare will not reimburse the ASC for silicone oil, perfluorocarbon, or a scleral buckle. Private payers might do so, depending on the contract with the ASC. Expect, however, that private payers will be inclined to follow Medicare's lead regarding denial of separate payment for those and other supplies.

The changes to the CPT eye codes prove that your office must be working from an up-to-date version of CPT. Make sure, as well, that you have recent versions of the other main coding and reimbursement documents, including the ICD-9-CM manual. Over time, the new codes will become second nature, but until then, make frequent checks of the relevant manuals to optimize payment for services rendered. OT