Ophthalmology and Optometry Coding Alert

Here’s what you can do right now to ensure you’re coding properly.

No coder wants to hear that there’s a RAC attack coming their way, but for most ophthalmology practices, that appears to be happening right now. RACs have made cataract surgery an audit focus effective within the last two months, and if your claims are found to be in violation, you could be facing paybacks.

Background: Recovery audit contractors (RACs) review Medicare claims for errors and collect a contingency fee based on the amount they recover. Much like MACs, there are different RAC contractors for the various regions in the country, and each one publishes the open issues that it is in the process of auditing.

One such issue on the plate for 2017 with multiple RAC regions involves cataract removal. Regions two and three (RAC contractor Cotiviti) and Region one (RAC contractor Performant Recovery) have recently announced that they’ll be reviewing the following issue involving cataract surgery:

• Complex Comprehensive Cataract Removal: “Documentation will be reviewed to determine if cataract surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary,” both Performant and Cotiviti say in their detail pages for this audit issue.

Know the Right Way to Code These Services

Complex comprehensive cataract removals are reported with 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) and require proof that the surgery was not routine. For example, the local coverage determinations (LCD) from Part B MAC CGS Administrators, which was just updated in March, 2017, allows this code for conditions that include the following:

• A miotic pupil that won’t dilate enough to allow the doctor to visualize the lens in the eye’s posterior chamber, requiring the insertion of four iris retractors through four additional incisions, Beechler or similar expansion device, a sector iridectomy with subsequent suture repair of iris sphincter, synechialysis utilizing papillary stretch maneuvers or sphincterotomies created with scissors.
• A disease producing lens support structures that are abnormally weak or absent, requiring support of the lens implant with permanent intraocular sutures and/or a capsular support ring to place the intraocular lens.  
• More difficult or more extensive surgery due to the patient’s pediatric status.
• Extraordinary work during the postoperative period, which is often true of pediatric cases “and very rarely when there is extreme postoperative inflam­mation and pain,” the LCD says.

Your documentation will differ based on the diagnosis code that necessitates a complex procedure. For instance, CGS says, you’ll might report one of these codes if you see the following notes in the record:

• Code H25.89 (Other age-related cataract) typically applies “if the operative note indicates dye was used to stain the anterior capsule.”
• You may turn to H28 (Cataract in diseases classified elsewhere) “if the operative note or postoperative records indicate an extraordinary amount of work was involved in the preoperative or postoperative care.”
• In cases when the op note says the intraocular lens was supported in the eye with permanent intraocular sutures, a capsular support ring was employed, or the doctor used an endocapsular ring for partial pupil occlusion, you’ll consider Q13.1 (Absence of iris).

Note: The above is not an exhaustive list — there are many other diagnoses and documentation examples that can justify the use of 66982. See your individual LCD for details.

Other payers differ: Palmetto, on the other hand, includes different examples of allowable situations that allow for 66982, as follows (although Palmetto stresses that this list is not all-inclusive):

• Insertion of iris retractors through additional incisions
• Mechanical expansion of the pupil using hooks
• Creation of a sector iridectomy with subsequent suture repair of iris sphincter
• Use of a Malyugian ring and multiple iris sphincter­otomies created with scissors.  
• The need to support the lens implant with permanent intraocular sutures
• Placement of a capsular support ring necessary to allow secure placement of an intraocular lens
• Performance of pediatric cataract surgery with intraocular lens insertion
• Use of intraocular dyes (e.g. trypan blue or indocyanine green) to stain the lens capsule in the setting of a mature cataract.

If you do get a notification that your cataract records are being audited by one of the RACs, don’t panic. Gather your documentation and all supporting notes to be ready for the auditor — and if your documentation is thorough and complete, you’ll likely pass the audit with flying colors.

Resource: To read the audit issue detail on the RAC pages, visit http://www.cotiviti.com/healthcare/who-we-serve/cms-approved-issues and https://www.dcsrac.com/IssuesUnderReview.aspx.