Although most ophthalmologists were relieved when the expected 10.1% cut in Medicare Part B payments for 2008 was replaced with a 6-month, 0.5% increase, other changes to the surgical Current Procedural Terminology (CPT) codes used extensively by vitreoretinal surgeons remain. The most significant change is the American Medical Association's (AMA) decision to delete CPT/Healthcare Common Procedure Coding System (HCPCS) code 67038 (strip retinal membrane). The AMA replaced this code with three newly created codes, in an attempt to better delineate the surgical procedure. The replacement of 67038 with these new codes will have a negative impact on surgical reimbursement, as outlined below.

The most significant impact will be seen with surgical repair of traction retinal detachments and retinal detachments complicated by proliferative vitreoretinopathy. The surgical repair of these complex retinal detachments in years prior to 2008 was best described by reporting CPT code 67108 (repair detached retina) and code 67038 (strip retinal membrane). The second code, represented by the lower relative value unit (RVU), was reported with a 51 modifier, resulting in reimbursement of 100% of the first code and 50% of the second code (Table 1).

NEW CODE DEVELOPED
With the deletion of 67038 in 2008, there was no longer an appropriate way to bill for the repair of complex retinal detachment with membrane peeling. Therefore, the AMA developed a new CPT code, 67113 (repair retinal detachment, complex), which includes repair of the retinal detachment, including the membrane peeling. Also included in code 67113 is scleral buckling, laser retinopexy, lensectomy, and gas or oil tamponade. Unfortunately, the RVUs assigned to this code have resulted in a reimbursement level only marginally higher than code 67108 alone. The net effect on the reimbursement of repair of complex retinal detachments that require membrane peeling is more than $640 per case, on a national level. Please refer to your geographical practice cost index (GPCI) for your local significance.

In addition, the deletion of code 67038 results in a negative effect on the reimbursement of surgery to repair macular pucker and macular holes. New codes were developed specifically for repair of macular pucker (67041), removal of internal limiting membrane (67042), and removal of subfoveal neovascular membranes (67043) (Table 2). Similarly, the RVUs assigned to these new codes resulted in a reduction in the reimbursement of more than $300 per case on a national level, depending on the code.

BETTER DEFINITION
Finally, CPT code 67229 is a new code for 2008 and is reported for laser or cryotherapy treatment of retinopathy of prematurity performed from birth to up to 1 year of age. The addition of this code allows for a better definition of treatment in this unique patient population and makes it unnecessary to use CPT code 67228 (panretinal photocoagulation) to report this treatment.

Mitchell S. Fineman, MD, is a partner with Mid Atlantic Retina in Philadelphia and Bryan D. Caruth is Business Manager at Mid Atlantic Retina. Dr. Fineman is an Assistant Surgeon at Wills Eye Institute and an Assistant Professor of Ophthalmology at Thomas Jefferson University, Philadelphia. He may be reached at +1 800 331 6634.