Ophthalmological Sessions within the Aftercare Period

For many ophthalmological procedures found in CPT, a single code represents one or more sessions within a specified aftercare period. For example, CPT 67101 is defined as follows:

CPT code:
67101
Repair of retinal detachment, one or more sessions, cryotherapy or diathermy, with or without drainage of subretinal fluid

The maximum allowable charge assigned by HMSA for such a procedure includes all services rendered within a 90-day aftercare period. If the patient needs repeat sessions within the aftercare period, payment for the additional sessions is considered to be included in the single inclusive payment made by HMSA for the original procedure. When it is necessary to perform a different procedure, separate payment will be made.

Claims Filing Information

When billing for ophthalmological procedures, in addition to providing the appropriate CPT codes, please use an appropriate modifier code (-LT for left or -RT for right) to designate to which eye(s) the services were rendered.

Example 1

Repair of retinal detachment is performed on a patient's left eye three times during the 90-day aftercare period.

Services billed:
06/01/96 - 67101- LT
07/15/96 - 67101- LT
08/07/96 - 67101- LT

HMSA will:
Pay 67101-LT once. The June 1 procedure includes any necessary additional services required and rendered within the 90-day aftercare period.

Example 2

The patient in the above example requires continued treatment beyond the 90-day global aftercare period.

Services billed:
09/08/96 - 67101- LT
09/25/96 - 67101- LT

HMSA will:
Pay 67101-LT once. The procedure dated September 8 begins a new 90-day aftercare period; additional payment for the additional procedure will not be allowed.

Revision History