CPT Code 67228

CPT code 67228 is a medical billing code for treatment procedures related to retinopathy, typically involving laser surgery.

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What is CPT Code 67228

CPT code 67228 is designated for a procedure involving the treatment of proliferative diabetic retinopathy, specifically using scatter laser photocoagulation or panretinal photocoagulation. This code is used when the procedure is performed in one or more sessions, typically to manage or slow the progression of the disease by targeting areas of the retina away from the central macula.

Does CPT 67228 Need a Modifier?

For the CPT code 67228 (Treatment of extensive or progressive retinopathy, one or more sessions; photocoagulation), several modifiers may be applicable depending on the specific circumstances of the treatment provided. Here is an ordered list of potential modifiers and the reasons for their use:

1. -LT (Left side): Used to indicate that the procedure was performed on the left eye.

2. -RT (Right side): Used to indicate that the procedure was performed on the right eye.

3. -50 (Bilateral procedure): Applied when the procedure is performed on both eyes during the same operative session.

4. -58 (Staged or related procedure or service by the same physician during the postoperative period): This modifier is used when a subsequent procedure is planned at the time of the first procedure and is part of the treatment course.

5. -79 (Unrelated procedure or service by the same physician during the postoperative period): Used if a new procedure (unrelated to the initial procedure) is performed while the patient is still in the postoperative period for the initial procedure.

6. -22 (Increased procedural services): Indicates that the work performed was substantially greater than typically required for the procedure due to specific circumstances.

7. -76 (Repeat procedure by same physician): Used if the procedure needs to be repeated by the same physician; can be relevant if initial treatment outcomes were insufficient and repeat treatment is necessary.

8. -77 (Repeat procedure by another physician): Used if the procedure is repeated by a different physician, which might occur in a multi-specialist practice or if the initial treating physician is unavailable.

Each modifier provides a way to specify details about how and under what circumstances the procedure was performed, which can affect billing and reimbursement processes. It's essential to choose the correct modifier(s) to ensure accurate billing and to avoid payment delays or denials.

CPT Code 67228 Medicare Reimbursement

The CPT code 67228, which refers to treatment for proliferative retinopathy (typically by means of panretinal photocoagulation, or PRP), is generally reimbursed by Medicare. This procedure is recognized as a necessary treatment for certain stages of diabetic retinopathy, which is a common condition in the Medicare population due to the prevalence of diabetes among older adults.

The reimbursement amount for CPT code 67228 can vary based on several factors including geographic location, the setting in which the procedure is performed (hospital outpatient department vs. an office), and the specifics of the Medicare plan. However, Medicare provides a base payment rate which can be adjusted by these factors.

For a more accurate and specific reimbursement rate, it is advisable to consult the Medicare Physician Fee Schedule (MPFS) available on the Centers for Medicare & Medicaid Services (CMS) website or through Medicare administrative contractors that manage claims and payments in specific regions. This will provide the most current and applicable information for billing and reimbursement for this procedure.

Are You Being Underpaid for 67228 CPT Code?

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