Ophthalmology and Optometry Coding Alert

Determining what your insurers consider “complex” is key.

Your practice probably knows the cataract coding rules by heart, but when it comes to any cataract procedures that are more complex than the standard service, coding the notes may stop you in your tracks.

Complex surgeries don’t take place frequently, and should most certainly be in the minority of your submissions. But if you truly do treat a patient with a complex extraction, study the following myths, along with their accompanying realities, to ensure that you’re coding accurately.

Myth 1: All Cataract Extraction Codes Pay the Same.

Reality: Although you may think the cataract excision codes are interchangeable because “they all pay the same,” the reality is that there’s a significant difference between them. According to the 2016 fee schedule, Medicare carriers will reimburse $806.31 for CPT® code 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [1-stage procedure], manual or mechanical technique [eg, irrigation and aspiration or phacoemulsification], complex, requiring devices or techniques not generally used in routine cataract surgery [eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis] or performed on patients in the amblyogenic developmental stage).

Medicare will reimburse $648.42 for CPT® code 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [1 stage procedure], manual or mechanical technique [eg, irrigation and aspiration or phacoemulsification]).

Therefore, it’s in your best interest to appropriately identify a complex surgery and bill for it when the documentation supports it.

Myth 2: ‘Complex’ Doesn’t Just Mean Extra Time

Reality: Many coders are accustomed to quantifying a procedure as “complex” when the surgeon spends more time than usual performing it, but that’s not necessarily the only way a payer would consider a cataract procedure to be complex. The key phrase in the descriptor is “requiring devices or techniques not generally used in routine cataract surgery … or performed on patients in the amblyogenic developmental stage.”

You’ll want to check with your payer on its specific guidelines for what’s considered “complex,” but using the Wellcare policy as an example since Wellcare updated it just this past February, you’d want to look for one of the following:

• Age  of  the  patient: If the patient is under the age of 18, the surgery “may be more difficult intraoperatively because of an anterior capsule which is more difficult to tear, cortex which is more difficult to remove, and the need for a primary posterior capsulotomy or capuslorhexis,” Wellcare says. If this is the case, you could be justified in reporting 66982.
• Use of dye during surgery due to poor visualization: If the surgeon needs to use Trypan or Indocyanine Green Dye to visualize the surgical field, you could qualify for using 66982.  
• Pupil or iris issues: In cases when the patient has a miotic pupil, Floppy Iris Syndrome or their pupil won’t dilate, the surgeon may have more difficulty visualizing the surgical field and may have to use retractors, which could justify using 66982.
• Surgical history: In cases when the patient has had a previous eye surgery such as a vitrectomy, the physician may find the cataract extraction more difficult than usual, resulting in the use of 66982.
• Complications. Even if the surgery is considered “typical,” you may still be able to report 66982 if the post-operative care goes above and beyond the normal case, or if you do encounter surgical complications that fall outside of what’s already included in the standard cataract extraction codes.

Myth 3: You’ll Only Identify Complex Procedures After the Fact.

Reality: Complex cataract surgery should be planned preoperatively whenever possible. The ophthalmologist will typically know ahead of time if it looks like the patient’s procedure will be complex, and should note it in the preoperative report. For example, she may note that the pupil looks miotic and may need to be expanded (noting the size of the pupil before and after manipulation), or that the patient suffers from hypermature cataract and will need dye for visualization.