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Vitrectomy with membrane peel and endo laser NOT detachment.

Marianne Posted Thu 26th of September, 2013 14:08:23 PM

OP NOTE: .....Vitrectomy instruments were placed inside the eye. The peripheral vitreous was shaved. Pick forceps were used and epiretinal membranes were peeled away from the puckered areas in the inferior mid periphery and inferior to the nerve and then an air/fluid exchange was carried out. Indocyanine green was dripped over the macular area. After a minute, it was removed. Balanced salt was placed back into the posterior pole. Under high magnification, the epiretinal membrane and internal limiting membrane were peeled away from the fovea region. There was an old retinotomy site above the superotemporal arcade and them membranes were amputated at the insertion site at the old retinotomy site. After the membranes were all peeled, the laser endoprobe was used and 498 laser burnes were placed, mostly in the inferior periphery over areas were the membranes previously were. After the laser was complete.....

QUESTION: This is for a commercial payer (NOT Medicare), Can 67042 vit with membrane peel and 67039vit with endolaser, be coded on the same claim? I know they are bundled with CCI edits, but again this is a commercial payer. I am audited quarterly by an outside audit company and they have contradicted themselves and mark me off for billing them together and for not billing them together to commercial payers. I have felt that 67042 is the more extensive procedure and usually bill for just that, but don't want to leave money on the table if I can bill 67039as well and recoup some of the money for the endolaser probe. Thanks for your help.

SuperCoder Answered Thu 26th of September, 2013 19:37:22 PM

You cannot separately code for 67039 when 67042( a higher RVU procedure is being performed)together. It bundles as you mentioned..

This is how is it.CCI has paired several vitrectomy procedures into mutually exclusive bundles, which means that practitioners would not usually perform the two bundled codes together. If you do report the two codes separately without modifiers, Medicare payers will only reimburse for one of them.

Mark these edits: Code 67039 (Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation) is bundled into 67040 (... with endolaser panretinal photocoagulation), 67041 (... with removal of preretinal cellular membrane [e.g., macular pucker]), 67042 (...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]), and 67043 (...with removal of subretinal membrane [e.g., choroidal neovascularization], includes, if performed, intraocular tamponade [i.e., air, gas, or silicone oil] and laser photocoagulation).

A previous edit put 67039 into column 1 and 67040 into column 2 of a mutually exclusive bundle.In a mutually exclusive bundle (as with a column 1/column 2 bundle), Medicare payers will only recognize the column 1 procedure if you report the two together without modifiers.

So, if you were to report 67040 and 67039 together without a modifier, you would only see reimbursement for the column 1 procedure, 67040.

Also, 67040 is now bundled into 67042 and 67043. Code 67041 is bundled into 67040, 67042, and 67043; and 67042 is bundled into 67043.

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