Ophthalmology and Optometry Coding Alert

Learn which situations warrant separate coding of an intraocular lens.

Answer 1: C. CPT^® code 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique … complex, requiring devices or techniques not generally used in routine cataract surgery … without endoscopic cyclophotocoagulation) covers the complex cataract procedure.

All cataract procedures include the insertion of an intraocular lens (IOL) prosthesis. Whether you can bill for the lens depends on where the surgery takes place. If the procedure is performed in a facility setting, you would not be able to separately code for the lens supply. However, Medicare allows you to report V2632 (Posterior chamber intraocular lens) for a conventional IOL when placed in an office setting.

Don’t miss: Medicare only covers part of the cost of an astigmatism-correcting IOL (A-C IOL, also known as a Toric IOL) reported with V2632. For the additional cost, you would use HCPCS Level II code V2787 (Astigmatism correcting function of intraocular lens).

If the patient received a presbyopia-correcting IOL (P-C IOL), you would use HCPCS Level II code V2788 (Presbyopia correcting function of intraocular lens).

Note that Medicare will not pay the extra cost for V2787 or V2788, so responsibility for payment of the upgraded lens will ultimately fall to the patient. Why? “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.

Tip: For Part B Medicare beneficiaries, issue an Advanced Beneficiary Notice (ABN) to inform the patient of the Notice of Exclusion from Medicare benefits to clearly identify the non-payable aspects of a P-C IOL insertion. For all other payers, including Medicare Advantage plans, use a suitable waiver, not the traditional ABN Form CMS-R-131.

Thus, reporting V2787 or V2788 to Medicare is optional. The patient may ask you to do so in order to receive a denial that they can then show 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. Non-Medicare payers may cover A-C and P-C IOLs, so double-check their policies regarding specialty intraocular lenses prior to surgery.

Answer 2: D. Report CPT^® code 66985 (Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal) for the piggyback lens for a patient who has already had an IOL implant inserted. You would also use 66985 when the ophthalmologist inserts an IOL implant in a patient who had cataract surgery previously but did not have a lens implanted at the time of the initial surgery.

Keep in mind: If the ophthalmologist inserts the IOL prosthesis during cataract surgery, CPT^® directs you to use:

• 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis … complex …);
• 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)); or
• 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique … without endoscopic cyclophotocoagulation).

Note that you can only report the higher-reimbursing complex cataract code 66982 when the procedure requires devices or techniques not generally used in routine cataract surgery.

Answer 3: D. Look to CPT^® code 66986 (Exchange of intraocular lens) to report the exchange of a previously implanted IOL. Payment for both the removal of the old lens and insertion of the new lens is included in 66986, so you should not code each step separately with 67121 (Removal of implanted material, posterior segment; intraocular) and 66985 (Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal).

The exchange of an IOL is typically performed in cases of placement of a lens of the wrong power or incorrect positioning, as in this scenario where the IOL has been dislocated and cannot be safely repositioned.

Answer 4: B. When billing Medicare, you should not report 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) or 92136 (Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) twice (e.g., 76519-RT (Right side) and 76519-LT (Left side), or 76519-50 (Bilateral procedure)). However, you can report a portion of the service bilaterally.

Why? As it does with many other diagnostic tests, the Centers for Medicare & Medicaid Services (CMS) divides the A-scan (76519) and the IOL Master (92136) into two components, says Judy Seymour, ACS-OH, coder and biller for Eye Associates of the South in Biloxi, Mississippi. The Medicare Physician Fee Schedule marks the technical component (performing the test) with modifier TC (Technical component …), and the professional component (viewing and interpreting the results) with modifier 26 (Professional component).

Watch out: CMS assigns different bilateral statuses to each component. One unit of 76519 or 92136 includes the work done for the technical component (the measurement) of both eyes, so 76519-TC and 92136-TC are both inherently bilateral. However, the professional portion (the actual calculation of IOL power) of these codes (76519-26 or 92136-26) is inherently unilateral — meaning that the code includes the calculation of IOL power in a single eye.

Usually, the ophthalmologist will perform the scan on both eyes, but only calculate IOL power for the eye being operated on. If, however, the ophthalmologist needs to calculate IOL power in both eyes, you would code as follows:

• 92136-TC for the bilateral technical component
• 92136-26-50 for the bilateral professional component. Append modifier 50 to show the provider bilaterally performed this usually unilateral component.

Check with your payer because some require you to report the bilateral IOL calculations as 92136-26-RT and 92136-26-LT.

Note: “Some non-Medicare payers do allow the full test once per eye,” notes Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

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