As surgical procedures become more common in optometry practices, medical coding and record compliance can become areas of concern and exposure. From a medical record standpoint, major and minor surgical procedures require a separate narrative, often referred to as a surgical report. This report describes several key items: the surgical procedure; preparation of the surgical field; instruments and approach used by the surgeon; and a statement of patient status at the end of the procedure. 

Coding a surgical procedure first involves recognizing whether it is designated as minor (a global period of 0 or 10 days) or major (a global period of 90 days). Perhaps the most common mistake ODs make is to bill for an office visit on the same day as a minor surgical procedure. By definition, a minor surgical procedure already includes an office visit, so it should not be billed in conjunction with an office visit on the same date, unless it had nothing to do with the decision to perform the minor surgery. 

In managing a patient with recurrent corneal erosion (RCE), both types of procedures are performed: major surgery (65600–multiple punctures of anterior cornea, 90 days), as well as minor surgery (65435–removal of corneal epithelium with or without chemocauterization, 0 days; and 65778–placement of amniotic membrane on the ocular surface; without sutures, 10 days). This distinction is important to know because of the medical coding convention that must be followed for each type of procedure.

Clinical Situation	Codes Performed	Codes Allowed
Office visit	992XX–57	992XX–57
Anterior stromal puncture	65600–RT/LT	65600–RT/LT
Fitting of a bandage contact lens	92071
Office visit	992XX–57	992XX–57
Anterior stromal puncture	65600–RT/LT
Debridement of the cornea	65435–51–RT/LT	65600–51–RT/LT
Fitting of a bandage contact lens	92071–RT/LT
Placement of amniotic membrane	65778–RT/LT	65778–RT/LT

The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services clearly defines this.¹ For a major surgical procedure, you can separately report the office visit performed on the same date of service as the procedure using modifier -57.¹ A minor procedure, though, cannot be reported separately from the office visit. The same holds true for a visit with a new patient—the fact that the patient is “new” to the provider doesn’t justify reporting an office visit on the same date of service as a minor procedure. 

However, a significant and separately identifiable E&M service unrelated to the minor surgical procedure is separately reportable with modifier -25. The E&M service and minor surgical procedure do not require different diagnoses.

The problem arises when ODs improperly use these modifiers to get reimbursed for the office visit. The Office of Inspector General has taken a particular interest in the improper and fraudulent use of modifier -25.

Also consider the NCCI rules when performing multiple procedures on the same day. All of these procedures are allowed on the same day without conflict, with the exception of 92071 (fitting of a contact lens for ocular surface disease) and performing debridement (65435) on the same day as placement of the amniotic membrane (65778).^2,3 (While federal rules allow you to perform certain combinations of procedures together, check with your specific local carrier if its rules vary from the federal standards.)

The coding for these two RCE situations may look something like the table above based upon these procedure.

Providing these surgical services at the slit lamp highlights just how far optometry has come in providing state-of-the-art care. But with increased privileges comes increased responsibility for understanding the rules and regulations for medical coding and medical record compliance of these surgical procedures.

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1. Centers for Medicare & Medicaid Services. The National Correct Coding Initiative Policy Manual for Medicare Services. Jan 2015:I-17.
2. CCIPlus Module. www.CodeSAFEPLUS.com.
3. Centers for Medicare & Medicaid Services. The National Correct Coding Initiative Policy Manual for Medicare Services. Jan 2015:XI-12.