Ophthalmology and Optometry Coding Alert

Curious coding may kill your cataract reimbursement - documentation and modifiers will leave Medicare purring

Ophthalmologists perform thousands of cataract surgeries each year, which can lead to a fair share of post-op complications that can be difficult to code. Fair reimbursement for postoperative procedures for complications - such as after-cataracts - depends on airtight documentation and skillful modifier use.

Beware PCO Within Global

The problem: Posterior capsule opacification (PCO), also known as an "after-cataract," is one of the most common problems following cataract surgery (a report from the Surgeon General found that 41 percent of patients develop PCO within 48 months after cataract surgery). In PCO, residual lens epithelial cells, left behind during the original surgery, proliferate and migrate. The membrane behind the new inserted intraocular lens thickens, blurring the vision.

Diagnosis: ICD-9 code 366.53 (After-cataract, obscuring vision)

Treatment: To treat after-cataracts, ophthalmologists incise the posterior capsule with a yttrium aluminum garnet (YAG) laser, allowing the capsule to contract and stop obstructing the passage of light to the retina.

"After-cataracts develop slowly, with most patients not noticing blurred vision right away, since they have experienced such improved vision from the cataract surgery," says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif. "Many patients will not mention a complaint of blurred or decreased vision until cataract surgery is performed on the fellow eye and they notice the distinct difference in the clarity of their vision."

Cataract surgery procedures - including 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique, complex, requiring devices or techniques not generally used in routine cataract surgery or performed on patients in the amblyogenic developmental stage), 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis [one stage procedure]) and 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique) - have 90-day global surgical periods, so coding YAG procedures for the majority of patients is straightforward, says Armeda Smith, CPC, senior coding specialist for the ophthalmology department of the University of Texas Medical Branch in Galveston. Report 66821 (Discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [e.g., YAG laser] [one or more stages]) and link it to 366.53. No modifiers are necessary if the YAG procedure takes place more than 90 days after the original cataract surgery and the patient is not within a post-operative period for any other surgical procedure performed by your physician or group, Smith says.

Document Necessity for OR Returns

Ophthalmologists sometimes treat after-cataracts within the global period of the initial cataract surgery. In these cases, append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to 66821 to break it from the 6698x global surgical packages, Smith says. (A laser suite in the ophthalmologist's office fits within Medicare's definition of "operating room.")

Some carriers are reluctant to pay 66821 claims within 90 days after cataract surgery and have local coverage policies that discuss when it would be appropriate to perform the procedure, so be prepared to prove medical necessity, Duran says. For example, Trailblazer, the Medicare Part B carrier for Washington, D.C., Delaware, Maryland, Texas and Virginia, states: "The indications for YAG capsulotomy surgery within three months post-cataract surgery (i.e., documentation of preoperative uveitis, chronic glaucoma, diabetes mellitus, prolonged use of Pilocarpine, etc.) must be made available to Medicare upon request."

Catch: "Even if you have documented the medical necessity of performing the YAG laser capsulotomy within 90 days of the initial cataract surgery, be prepared to lose 30 percent of the normal reimbursement," Duran says. Medicare published a special payment rule for this procedure in the Federal Register ("Medicare Program Physician Fee Schedule Rules, CY 1993"):

"YAG laser capsulotomy is typically performed during the postoperative period of a cataract surgery as a result of complications from the cataract surgery and, therefore, should be paid at the intraoperative value of the procedure. Payment for the preoperative and postoperative work in the cataract surgery subsumes the preoperative and post-operative work in the YAG laser capsulotomy ... Therefore, full payment for the YAG laser capsulotomy would result in overpayment for the pre- and post-operative work in the service."

Translation: When the ophthalmologist performs a YAG capsulotomy within the global of cataract surgery, Medicare will not pay for the pre- and postoperative portion of the YAG procedure. The pre- and postoperative portion of the original cataract surgery, Medicare says, covers that payment.

The intraoperative portion of the global surgical package for 66821 is valued at 70 percent of the total RVUs (the pre-op is worth 10 percent, and the post-op is worth 20 percent). Based on Medicare's payment rule, if you bill 66821-78 performed in the hospital, you will be allowed $161 (70 percent of 6.08 RVUs = 4.256; multiplied by the 37.8975 conversion factor = 161.29, unadjusted for location) instead of the full $230 reimbursement.

Bill 66821 Once for Multiple Sessions

What if the patient had cataract surgery two years ago on the left eye, then had cataracts removed from the right eye last month - and then presented with a complaint related to after-cataracts in the left eye? It's within the global for the surgery on the right eye, but since the after-cataracts are in the left eye, it's not related to the latest surgery.

Report 66821 appended with modifiers -79 (Unrelated procedure or service by the same physician during the postoperative period) and -LT (Left side) to show that this new procedure is not connected with the most recent cataract surgery, says Samantha Lanzarotta, CPC, billing manager for Ophthalmic Surgeons and Physicians in Tempe, Ariz.

You have even more problems if the after-cataract takes more than one session to clear up. The phrase "one or more stages" appears in the description of 66821 and most other laser codes. This means you can only bill one laser procedure of the same code in a 90-day period on the same eye, Lanzarotta says, because these codes are defined as for one or more treatments.

Tip: Be sure to read the May issue of Ophthalmology Coding Alert, where we'll cover two other postcataract surgery complications: dislocated intraocular lens (IOL) and retinal detachment.