Ophthalmology and Optometry Coding Alert

All cataract procedure codes must be accompanied by one of the designated diagnosis codes in the primary list. Also, there's a secondary list for 66982. In this special medical-necessity listing, AdminaStar requires that in addition to one of the primary diagnoses, you must use one of the secondary diagnoses as well.

The secondary code list includes 364.51 (Disorders of iris and ciliary body; degenerations of iris and ciliary body; essential or progressive iris atrophy), 364.55 ( miotic cysts of pupillary margin), 364.57 ( degenerative changes of ciliary body), 364.59 ( other iris atrophy), 364.75 ( adhesions and disruptions of iris and ciliary body; pupillary abnormalities), 364.76 ( irido-dialysis), 364.8 ( other disorders of iris and ciliary body), 364.9 ( unspecified disorder of iris and ciliary body), 379.32 (Other disorders of eye; aphakia and other disorders of lens; subluxation of lens), 379.33 ( anterior dislocation of lens), 379.34 ( posterior dislocation of lens), 379.40 ( anomalies of pupillary function; abnormal pupillary function, unspecified), 379.41 ( ani-socoria), 379.42 (Miosis [persistent], not due to miotics), 379.43 (Mydriasis [persistent], not due to mydriatics), 379.45 ( Argyll Robertson pupil, atypical), 379.46 ( tonic pupillary reaction), 379.49 ( other), 743.36 (Congenital anomalies of eye; congenital cataract and lens anomalies; anomalies of lens shape), 743.37 ( congenital ectopic lens), 743.45 ( coloboma and other anomalies of anterior segment; aniridia) and 743.46 ( coloboma and other anomalies of anterior segment; other specified anomalies of iris and ciliary body).

AdminaStar also tells you when you should report certain diagnoses to support 66982. The carrier gives coders an idea how to select a code based on documentation and informs ophthalmologists how to document to support the diagnosis. For example, you should report 364.51 (... iris atrophy) "if the operative note indicates the use of an endocapsular ring to partially occlude the pupil," according to the LMRP. Similarly, you should code 364.57 (Degenerative changes of ciliary body) "if the operative note indicates that a permanent intraocular suture or a capsular support ring was employed to place the intraocular lens in a stable position." And use 364.8, 364.9 or 743.46 "if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, use of a Beechler or similar expansion device, creation of multiple sphincterotomies with scissors, sector iridotomy with suture repair of iris sphincter was performed, or a permanent intraocular suture, capsular support ring, or endocapsular support ring was used to partially occlude the pupil." (Sometimes the language says "a ring to partially occlude the pupil" instead of "endocapsular support ring.") Report 379.32 "if the operative note indicates the intraocular lens was supported by using permanent intraocular sutures or a capsular support ring."

Clearly, the LMRP attempts to control the use of 66982, a relatively new code that some carriers feared would be used by any ophthalmologist who deemed he or she should be paid more for cataract surgery. AdminaStar, by linking techniques to diagnoses, has chosen an efficient way to make its medical-necessity list work as a necessary-technique list.

It is rare to require two sets of diagnosis codes, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources, a coding, reimbursement and compliance consultancy based in Chicago. Usually, the secondary list is seen when a payer requires a V code followed by a reason or underlying symptom or vice versa. The idea of using a diagnosis code to describe a technique for a procedure is a "unique concept," Gilhooly says. "But it makes sense. This way, the payer can make sure the additional work was done without requiring providers to submit paper claims with the operative report attached." Gilhooly adds that the diagnosis code alone occasionally does not provide the medical necessity the payer is seeking. "It would be possible for a patient to have a condition without it being severe enough for a certain procedure."

You should remember to follow the principle that some cataract surgeries are easy, and some are hard. The cataract surgery codes are valued to include both. AdminaStar is trying to make it clear that you should not turn to 66982 every time you have a difficult cataract surgery only when you perform the techniques it describes.

The revised AdminaStar LMRP is effective April 15, 2002.