Ophthalmology and Optometry Coding Alert

Our expert answers for your frequently-asked 66982 questions.

With cataracts affecting nearly 22 million Americans older than 40 — and more than half of all Americans 80 and older — it would be surprising if your practice did not perform a good number of cataract surgeries each year. And with reimbursement for complex cataract surgery CPT® code 66982 at about $160 more than for cataract code 66984, it stands to reason that many ophthalmology coders are wondering what makes a cataract surgery qualify as “complex.”

Complex surgeries don’t happen that often, however: The American Academy of Ophthalmology estimates that only about 5 percent of the cataract cases in one year were complex cases. To justifiably report 66982 and claim your deserved reimbursement, the clinical circumstances have to be right, and your coding and documentation need to be rock-solid.

Question: What’s the difference in reimbursement?

Answer: According to the 2014 fee schedule, Medicare carriers will reimburse $837.80 for CPT® code 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), based on 23.39 relative value units (RVUs) multiplied by the conversion factor of 35.8228. 

Medicare will reimburse $673.11 for CPT® code 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [1-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]).

Question: So what makes a cataract surgery “complex”?

Answer: 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.” 

Look for the following in your ophthalmic surgeon’s documentation for a complex cataract case:

• Size of the pupil: If the pupil is miotic and will not dilate sufficiently to allow visualization of the lens in the posterior chamber, the surgeon may have to use devices such as iris hooks or ring expanders in order to gain access to perform the surgery. The narrow stricture may be due to use of drugs such as alpha blockers, or trauma to the eye, experts say.
• Weak or absent lens support: If the patient has a disease or condition that produces lens support structures that are abnormally weak or absent –for example, uveitis, Marfan syndrome, or pseudoexfoliation syndrome — the intraocular lens (IOL) that the ophthalmic surgeon inserts may need extra support, for instance with sutures or a capsular tension ring, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. 
• Poor visualization: If the cataract is unusually dense — such as a hypermature cataract (ICD-9 code 366.18) or white cataract (366.17) — the ophthalmic surgeon may need to inject dye such as trypan blue to help him visualize the anterior chamber.
• Youth of the patient: A pediatric patient is at risk of developing amblyopia, an example listed in the code descriptor. In addition, “pediatric cataract 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 capsulorrhexis,” says Medicare Advantage provider WellCare. “Additional postoperative work is associated with pediatric cataract surgery.”

Question: What documentation do we need?

Answer: Complex cataract surgery should be planned preoperatively, experts say. The ophthalmic surgeon should know ahead of time if she will need to perform 66982, 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. 

Question: What about surgical complications?

Answer: Do not report 66982 just because the ophthalmic surgeon encounters complications intraoperatively. For example, if the vitreous collapses during the cataract removal, and the ophthalmic surgeon has to perform a vitrectomy, that does not make it a complicated procedure. In this case, the vitreous collapse is an iatrogenic, or inadvertently induced, complication, and as such Medicare considers it included in the work performed in 66982. The Correct Coding Initiative (CCI) bundles vitrectomy codes 67005 (Removal of vitreous, anterior approach [open sky technique or limbal incision]; partial removal) and 67010 (... subtotal removal with mechanical vitrectomy) into cataract surgery codes 66982 and 66984.

However: If the ophthalmic surgeon knows about a pre-existing prolapsed vitreous (in other words, it is not an iatrogenic complication of the surgery) and notes in the preoperative report her plans to perform a vitrectomy, you can report 67005 or 67010 in addition to 66982.