Denise Posted Thu 13th of June, 2019 11:59:35 AM
I have a provider that did a right medial rectus disinsertion/reinsertion of the muscle for nystagmus. Can I still use 67311 if they did not recess or resect the muscle?
SuperCoder Answered Fri 14th of June, 2019 07:18:18 AM
Thank you for your question.
CPT® distinguishes the strabismus surgery codes (67311-67318) by whether the procedure involves horizontal, vertical or superior oblique muscles.
Since, the procedure was performed on the right medial rectus muscle, which is one of the horizontal muscles, CPT® code 67311 was the best choice of code to be reported.
But in the above provided documentation, it is mentioned that the provider did not recess or resect, therefore, you are advised to report the performed procedure with CPT® code 67399-Unlisted procedure, extraocular muscle, as there is no specific code that defines the strabismus surgery procedure, without recession or resection.
Hope that helps!