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.
WHAT IS THE DIAGNOSIS?
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 67105. If the same laser procedure is indicated for a retinal tear and prophylaxis of retinal detachment, CPT code 67145 is correct.
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IS THIS A MAJOR OR MINOR PROCEDURE?
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.
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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.
WHO IS THE PAYER?
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 2016, Medicare has assigned a 10-day global period to CPT code 67228 (treatment of extensive or progressive retinopathy [eg, diabetic retinopathy], photocoagulation), while some Medicaid plans still recognize CPT code 67228 as a major surgery with a 90-day postoperative period.
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Another good example is CPT code 67145—the global period changed in January 2022 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.
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