Ophthalmology and Optometry Coding Alert

Documentation is key – and stay away from the “unspecified” codes.

With more than 24 million Americans age 40 or older affected – and more than half of Americans over 75 – cataracts are a prevalent problem that show now sign of going away anytime soon. If your practice deals with a typical volume of cataract cases, you know there’s lots of room for errors and the potential to leave deserved reimbursement on the table.

Read on for expert tips on keeping your cataract coding and claims crystal-clear.

Cataract is defined as “an opacity or loss of clarity on the crystalline lens,” says Alice Marie Reybitz, RN, BA, CPC, COC, CPC-I, CCS-P, who led a “Coding for Cataract Surgery” seminar at the CodingCon conference. Age-related or senile cataracts are most common in adults, she says, but diabetes also contributes to the condition (when cataracts appear secondary to the disease process).

Pediatric cataracts are also a concern, and the condition can be caused by eye injury or in a toxic condition through drugs or a body process, Reybitz notes.

There are no medical treatments (e.g., drugs or injections, Reybitz says. “In general, cataract surgery is performed to replace the lens and relieve the opacity.”

Know the Medical Necessity Rules

Medicare – and payers that follow Medicare guidelines – will cover the costs of medically necessary cataract surgery, Reybitz says. For example, in its local coverage decision (LCD), Palmetto GBA, a Medicare Part B carrier, considers lens extraction medically necessary (and covered by Medicare) when one or more of these conditions exists:

1. Cataract causing symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function not correctable with a tolerable change in glasses or contact lenses, lighting, or non-operative means resulting in specific activity limitations and/or participation restrictions including, but not limited to reading, viewing television, driving, or meeting vocational or recreational needs.

2. Concomitant intraocular disease (e.g., diabetic retinopathy, or intraocular tumor) requiring monitoring or treatment that is prevented by the presence of cataract.

3. Lens-induced disease threatening vision or ocular health 4. High probability of accelerating cataract development as a result of a concomitant or subsequent procedure and treatments such as external beam irradiation.

5. Cataract interfering with the performance of vitreoretinal surgery.

6. Intolerable anisometropia (two eyes having significant differences in refractive power) or aniseikonia (a significant difference in the perceived size of images) uncorrectable with glasses or contact lenses exists as a result of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity).

Medicare will consider any conditions not covered in the above items on “the standard of care and other factors related to medical necessity,” Reybitz notes. “Logging into your professional websites can be of great assistance here. Often, they have great guidance for the standards.”

Watch for: Your ophthalmic surgeon should not base his decision on lens opacity alone. “Surgery is not deemed to be medically necessary purely on the basis of lens opacity in the absence of symptoms,” says Palmetto.

Also, the Snellen visual acuity chart results should be documented and will be considered toward medical necessity – but they’re not enough on their own, Palmetto says.

“Testing only with high-contrast letters viewed in dark room conditions will underestimate the functional impairments caused by some cataracts in common real-life situations,” the LCD says. “While a single arbitrary objective measurement might be desirable, a single Snellen visual acuity alone can neither rule in nor rule out the need for surgery.”

Know Your Doc’s Documentation

The patient’s medical record must include specific documentation, Reybitz explains.

For a visually symptomatic cataract, the record must contain:

• A statement that describes specific symptomatic impairment of visual function resulting in specific activity limitations
• The patient’s own words describing his condition. “This makes the documentation real,” Reybitz emphasizes.
• A statement or measurements showing that the patient’s visual impairment is not correctable with a tolerable change in glasses or contacts. “Past exam findings included here would be helpful if the deficit has changed,” Reybitz says.
• A best-corrected Snellen visual acuity at distance under standard testing conditions. “Neither uncorrected visual acuity nor corrected visual acuity with the patient’s current prescription will satisfy this requirement,” warns Reybitz. This refraction must be performed by the surgeon or suitably trained staff. When cataract is the primary cause of impairment, the degree of lens opacity should correlate with the impairment, Reybitz says.
• If there are co-existing ocular diseases, the medical record should indicate that the cataract is the primary cause of visual compromise.
• A statement that the patient desires surgical correction, and that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that lens surgery will significantly improve both the visual and functional status of the patient. “It is very important to include the patient in all this documentation,” Reybitz says.

More Specificity Means Avoiding “Unspecified” Diagnosis

The ICD-10 diagnosis codes for cataract – those that will support medical necessity – are within the H25.011-H25.89 range for age-related cataracts and the H26.001-H26.8 range for other cataracts.

Most of these codes have six characters, which specify details such as the specific kind of cataract and what eye it occurs in. With all the documentation requirements for billing, there should be no need for the “unspecified” cataract codes H25.9 and H26.9, Reybitz cautions.

66982-66984 Are Common CPT^® Codes – But Watch for Audits

The most common CPT® codes for cataract surgery, according to Reybitz, are:

• 66982 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage
• 66983 – Intracapsular cataract extraction with insertion of intraocular lens prostheses (1 stage procedure)
• 66984 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification).

These are also the most commonly audited codes for documentation compliance, Reybitz notes.

Watch for: Don’t report 66982 just because the ophthalmologist encountered a surgical complication, such as the need to perform a vitrectomy. A true complex cataract extraction is prospectively planned based on pre-existing conditions.

Report 66982 only if the ophthalmologist knows preoperatively that the procedure is necessary and meets the requirements of the code descriptor. Documentation in the medical record prior to the surgery will support this decision.

Other CPT® codes you may encounter are:

• 66830 – Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy)
• 66840 – Removal of lens material; aspiration technique, 1 or more stages
• 66850 – … phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration
• 66852 – … pars plana approach, with our without vitrectromy
• 66920 – … intracapsular
• 66940 – … extracapsular (other than 66840, 66850, 66852).

Second eye: If a symptomatic cataract is present in both eyes, the surgeon will generally only perform the surgery on the first eye because of the potential for visual loss in both eyes, Reybitz says. More commonly, the second cataract will be addressed after an “appropriate interval,” she says.

Don’t Forget PC- or AC-IOL Extras

Every cataract procedure includes the insertion of an intraocular lens prosthesis. If the procedure is performed in a facility setting, you would not be able to code separately for the lens supply. However, in an office setting, Medicare allows you to report V2632 (Posterior chamber intraocular lens) for a conventional IOL.

If the patient receives IOLs that correct presbyopia or astigmatism, Medicare will still only pay the cost of a standard IOL; the patient will be responsible for the extra cost for the presbyopia or astigmatism correction.

You can code this extra portion with HCPCS code V2787 (Astigmatism correcting function of intraocular lens) for an astigmatism-correcting IOL (AC-IOL, also known as a toric IOL). Code the extra cost of a presbyoptia-correcting IOL (PC-IOL) with V2788 (Presbyopia correcting function of intraocular lens).

Medicare will not pay the extra cost, so the responsibility for payment for V2787 or V2788 will ultimately fall to the patient.

Rationale: “A single P-C IOL or A-C IOL essentially provides what is otherwise achieved by two separate items: an implantable conventional IOL (one that is not presbyopia- or astigmatism-correcting), and refractive correction similar to the correction provided by refractive surgery, eyeglasses or contact lenses,” says Medicare.

Reporting V2787 or V2788 to Medicare is optional. The patient may ask you to do so in order to receive a denial that he can then submit to a secondary payer to receive payment. In that case, append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit) to the V code.