Ophthalmology and Optometry Coding Alert

At least one Medicare carrier has issued a local medical review policy (LMRP) for 66982, the new complicated cataract surgery code that is creating confusion among ophthalmologists. Released April 15, Blue Cross and Blue Shield (BC/BS) of Kansas LMRP for 66982 is being referred to by field experts as a model for the code. The carrier covers Kansas, Nebraska and Northwestern Missouri.

The LMRP gives four indications for the code:

1. A miotic pupil that cannot be sufficiently dilated to visualize the lens and the posterior chamber of the eye, and that requires four iris retractors through four additional incisions, a Beechler expansion device, a sector iridectomy with subsequent suture repair of iris sphincter or sphincterotomies created with scissors.

2. A disease state that results in abnormally weak or absent lens support structures. The lens implant must be supported with permanent intraocular sutures, or a capsular support ring may be required. (The LMRP notes that capsular support rings have not been approved by the FDA, and therefore are not covered by Medicare.)

3. Pediatric surgery that is complicated by an anterior capsule that is difficult to tear, a cortex that is difficult to remove and the need for a primary posterior capsulotomy or capsulorrhexis. (The LMRP adds that pediatric cataract surgery requires additional postoperative work.)

4. Extraordinary work during the postoperative period. This occurs with pediatric cases mentioned in the above point, and also, but very rarely, when there is extreme postoperative inflammation and pain.

The four indications encompass more than CPTs list of examples. Note that anterior vitrectomies do not constitute a reason to bill 66982.

Diagnosis Codes

An LMRP, unlike CPT, can use diagnosis codes to limit the billable use of a procedure. BC/BS Kansas lists the following diagnosis codes as supporting medical necessity for 66982: 364.23, 364.51, 364.55, 364.57, 364.59, 364.75, 364.76, 364.8, 364.9, 366.18, 366.20, 366.21, 366.22, 366.30, 366.32, 366.33, 379.32, 379.33, 379.34, 379.40-379.49, 743.36, 743.37, 743.45, 743.46.

In every case, the diagnosis, in order to be allowed, also requires certain procedures to be followed during surgery, as indicated by the operative note. For example, to bill 379.4x (anomalies of pupillary function), the operative note must indicate use of micro iris hooks through four separate incisions, Beechler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris placed in the eye.

To bill 366.18 (hypermature cataract), there must also be a diagnosis of 365.51 (phacolytic glaucoma), or you must indicate dye staining of the anterior capsule.

To bill 366.30 (cataracta complicata, unspecified), the operative note must indicate use of iris hooks through four separate corneal incisions, Beechler or similar expansion device, multiple [...]