Ophthalmology and Optometry Coding Alert

Ophthalmologists and their coders may be tempted to use the new cataract surgery code frequently, but according to Michael X. Repka, MD, CPT advisor for the American Academy of Ophthalmology (AAO), overuse will result in two things: a devaluation of the relative value unit (RVU) and punitive audits. Im sure its going to be an audit target already, Repka says.

The safest way to use 66982 (extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification], complex, requiring devices or techniques not generally used in routine cataract surgery [e.g., iris expansion device, suture support for intraocular less, endocapsular rings, or primary posterior capsulorrhexis] or performed on patients in the amblyogenic developmental stage) is for the examples given in the code descriptor.

But 66982 can be used for other techniques as well, says Repka, who practices at the Wilmer Eye Institute in Baltimore. Whats given in CPT is just a list of examples, he says. Repka gives another example of complicated cataract surgery that would justify use of the new code:

If the physician has to cut the iris apart because the pupil is small, and then suture it back together, that would qualify for 66982. A hypermature cataract, a hard lens that takes a long time to remove, a phacofragmentation that fails these are all within the normal limits of the regular cataract surgery codes, he says. Do not use 66982 for those situations.

Im not surprised that there are a lot of inquiries on when to use this code, says Lise Roberts, vice president of Health Care Compliance Strategies, a company based in Jericho, N.Y., that develops interactive compliance training courses. If HCFA determines that the code is being widely abused, worst-case scenario, the code could be deleted from future CPT editions, Roberts says. A less extreme solution, which has been employed more than once by HCFA to address overuse of a code, would be to establish a payment policy that the new code would be paid at exactly the same rate as 66984 and let the new code remain in CPT for other payers.

HCFA estimates that 66982 will have a use of about 2 percent, Repka says. Overuse will result in a close look at and probably a decrease of the RVU for this code. That would be unfortunate, because the code and the value were hard-won for truly complicated surgeries.

Clearly, HCFA is concerned that at least some physicians will abuse the code. But as long as the national use doesnt exceed 2 percent, Roberts says, the agency will likely keep the code, allow the extra payment, and pursue specific doctors who have a significantly greater than 2 percent utilization rate in their practice compared to other doctors in their geographical area.

The AAO knew that establishing the new code was a calculated risk but argued that it could educate its members to use the code properly.

As attractive as 66982 may be to ophthalmologists looking for reimbursement for difficult cataract surgeries, coding in order to raise reimbursement is fraud.