tci Outpatient Facility Coding Alert - 2017 Issue 5

Reader Question: When Billing Unilateral, Bilateral Procedures, Look to Op Note for Clues

Question: Our ophthalmologist resected the lateral rectus muscles of both of the patient’s eyes during a strabismus surgery and marked 67312 (Strabismus surgery, recession or resection procedure; 2 horizontal muscles) in the op note, but our office manager said that was incorrect. Can you advise? Supercoder.com Subscriber Answer: The strabismus surgery CPT® codes (67311-67318) describe unilateral procedures, or procedures performed on one eye only. Although the surgeon resected two muscles total, they were in different eyes, so 67312 is not correct. Instead, you should report 67311 (Strabismus surgery, recession or resection procedure, 1 horizontal muscle) bilaterally. In...

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