Trying to put a square peg in a round hole just isn’t going to work. Often, that’s what it seems like when trying to code for some retina/vitreous surgical procedures—one of them being removal of silicone oil that has been used in prior retinal detachment surgery.

Although the Current Procedural Terminology (CPT) coding book gives clear instructions not to use a code that is not exact, but rather to use an unlisted code, one that ends in 99, such as 67299 (Unlisted procedure, posterior segment), this is a problem for ASCs and physicians alike. For ASCs there is no Medicare payment methodology so an unlisted code cannot be used, and for physicians—it becomes a long process with no guarantee of appropriate payment.

With Medicare changes in payment for CPT retina/vitreous surgery codes, as well as the proliferation of code-pair edits (bundles) in the National Correct Coding Initiative (NCCI), the year 2020 seems to be a good time to reconsider whether to make adjustments in CPT code selection in order to remain in compliance while optimizing reimbursement. Proper coding for the removal of silicone oil after retinal detachment surgery—be it in the anterior or posterior segment—presents some of the most challenging and controversial coding choices.

This article will discuss the CPT code choices followed by a complicated case example. All coding advice is based on current Medicare payment guidelines. Please consider this particular column a blog, replete with my take on the issues.

THE CONUNDRUMS

The CPT process is one by which a code is formulated for inclusion in the CPT code book, and then the reimbursement is valued by the Relative Value Scale Update Committee Update Committee (RUC) for recommendations to the Centers for Medicare and Medicaid Services (CMS). This is a prolonged, tedious, and work-intensive process, and one that is not easily mastered in any of the steps along the way.

So, here are some of the issues that bear discussion when reviewing CPT coding of removing previously inserted silicone oil from either the anterior chamber or the posterior segment.

CPT CODE CHALLENGES

The codes in play are listed in Table 1.

Conundrum #1: Use of CPT code 67036.

There is no specific CPT code that describes removal of silicone oil, per se, from either the anterior or posterior segment. Furthermore, in medical terminology, the suffix –ectomy equates to “removal of.” In all these cases removal of most of the vitreous has already been performed for the original treatment of the retinal detachment; thus, the work, time, and intensity of the value assigned to CPT code 67036 is not being performed.

So, should CPT code 67036, pars plana vitrectomy, be coded for the removal of silicone oil when the surgery does not involve removal of vitreous or even the descriptor of removal of implanted material, and more specifically, silicone oil?

The surgery for CPT code 67015 is described in coding manuals as “…inserts a needle into through posterior chamber [sic] through the pars plana to aspirate vitreous. Sometimes a posterior sclerotomy is made to release the fluid…extracts the vitreous, using a mechanical cutting and suction process that may involve a rotoextractor or vitreous infusion suction cutter (VISC). This is often called a vitreous tap in operative reports...” Associated diagnoses are all disease entities and none are implanted material removal. It appears that this is not a proper code for aspiration of implanted material (i.e., silicone oil).

Surgery for CPT code 67121 is described in coding manuals as “An incision is made in the pars plana near the site of an intraocular lens that has fallen into the posterior segment of the eye…removes the extracapsular IOL from the eye…closes the incision with sutures and may restore the intraocular pressure with an injection of vitreous substitute.”

Long-term discussions have ensued and various coding suggestions have been proposed regarding whether or not code 67121 can be used for coding the removal of silicone oil. In fact, a new or revised and more generic CPT code, one that is generic for removal of any previously implanted material in the posterior segment is needed, one that applies to removal of silicone oil—perhaps by a change in the descriptor of CPT code 67121. In the absence of such a code, my recommendation to use CPT code 67121 whenever applicable is based on the following:

• A prior pars plana vitrectomy has already been performed. As the eye has already been vitrectomized with minimum vitreous remaining, CPT code 67121 may be a better choice than 67036 because its descriptor is more accurate.
• Medical necessity also should be considered. The current procedure being performed may be due to the standard practice of removing silicone oil after the retina is stabilized to prevent further complications of raised intraocular pressure or due to destabilization of the oil or other complications that necessitate its removal and even a new reinsertion. This is true for both presence of silicone oil in the anterior segment, always considered a complication, and posterior segment removal.
• Silicone oil is, in fact, implanted material that is being removed and not a disease/injury or traumatic/nontraumatic occurrence that is being treated.

Conundrum #2: Which CPT Codes to Use in View of Medical Necessity?

Coverage of Services

Medicare coverage of services has always been based on the purpose of the service rather than the ultimate diagnosis of the patient’s condition. Thus, the principal coding of surgical cases should be guided by the purpose of the surgery, not by other procedures that may also be performed incidentally, such as prophylactic laser.

Selecting the Order of CPT Codes

Normally, one lists the order of multiple CPT codes with the highest paying code first. However, sometimes bundling under the NCCI kicks in, and then all of the codes cannot be used. Again, the codes selected for the example below should be chosen by the purpose of the procedure.

The focal endolaser pays more, but the medical necessity and purpose of the surgery is for the removal of the silicone oil, not for the prophylactic procedure.

Conundrum #3: Which CPT Codes to Use in View of the NCCI bundles?

Frequently, I am sent cases for coding wherein prior retinal detachment repairs using silicone oil had occurred and there is medical necessity for removal of the silicone oil as well as an exchange of an intraocular lens. There are NCCI bundles between the following code pairs 67036 and both 67121 and 67015, as well as 67121 and 67015. There are also NCCI bundles between 67121 and vitrectomy with focal endolaser photocoagulation (67039) and endolaser panretinal photocoagulation (67040). Use the codes dictated by purpose and medical necessity.

Conundrum #4: Instruments vs. Surgical Techniques

In my recent article, “MIGS 2020,” which was featured in the February 2020 issue of The Ophthalmic ASC, I discussed this issue in terms of coding an operation using the surgical technique described in the CPT descriptor—not the instrument used nor the branded device itself.¹ Thus, a vitrectomy instrument used for removal of silicone oil does not equate to performing a vitrectomy. Instruments are not issued CPT codes. Surgical procedures are.

Conundrum #5: How to Code for Removal of Silicone Oil From the Anterior Chamber/Segment?

This coding presents problems similar to coding procedures in the posterior segment. The paracentesis code descriptors for CPT codes 65800, 65810, and 65800 (often described as anterior chamber washout) usually are not as accurate a descriptor as CPT code 65920 (Removal of implanted material, anterior segment of eye). The ease and accuracy of using this code is seductive.

A COMPLICATED CASE INVOLVING RETAINED SILICONE OIL IN BOTH THE ANTERIOR AND POSTERIOR SEGMENTS

The following are excerpts from a very complicated case.

DIAGNOSES:

1. H35.341 Macular hole, right eye
2. T85.698A Complication of other…implanted material in posterior segment (retained silicone oil)
3. T85.398A Other mechanical complication of other ocular prosthetic devices, implants and grafts
4. Z98.890 Personal history of prior surgery

CONCLUSION

The problem of not having an accurate CPT code that describes the surgery actually performed is not uncommon. The challenge remains, and the solution is obvious: Obtain a revision of the current code descriptions/examples for CPT 67121 that encompasses other implanted materials or develop a new CPT code for removal of silicone oil. Hopefully, this will happen in the not too distant future. ■

Reference

1. Asbell, RL. MIGS 2020: Medicare’s New Compliance and Reimbursement Regulations. The Ophthalmic ASC. February 2020.

CPT codes Copyrighted 2019 American Medical Association.