Ophthalmology and Optometry Coding Alert

Every cataract procedure includes an IOL – but there are situations where separate coding is warranted.

Answer 1: D. CPT® code 66986 (Exchange of intraocular lens) describes the exchange of a previously implanted IOL. Payment for both the removal of the old lens and insertion of the new lens are included in 66986, so you should not code 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).

IOL exchange is usually performed in the case of an incorrect positioning of the placement of a lens of incorrect power – or, as in this scenario, the IOL has been dislocated and cannot be safely repositioned. If the ophthalmologist is inserting an IOL implant in a patient who had cataract surgery previously but did not have a lens implanted at the time of the previous surgery, you would report 66985.

Answer 2: C. 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) covers the complex cataract procedure. 

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. 

However: With V2632, Medicare only covers part of the cost of an astigmatism-correcting IOL (AC-IOL, also known as a toric IOL). For the additional cost, you would use HCPCS code V2787 (Astigmatism correcting function of intraocular lens). 

If the patient received a presbyopia-correcting IOL (PC-IOL), you would use HCPCS code 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 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.  

Answer 3: 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 report that code for a patient who underwent previous cataract surgery, but did not have an IOL inserted at that time.

Watch for: If the ophthalmologist inserts the piggyback IOL during cataract surgery, CPT® directs you to 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 [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 prosthesis[1- stage procedure] ) or 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis, manual or mechanical technique).

Note that insertion of a piggyback lens itself is not justification to report the higher-reimbursing complex cataract code 66982.

Answer 4: False. You should not report CPT® code 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 and 76519-LT, or 76519-50), even if the ophthalmologist calculates IOL power in both eyes. However, you can report a portion of the service bilaterally.

Medicare splits both CPT® codes 76519 and 92136 into technical and professional components, but it 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 a single code only includes 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 (Bilateral procedure) to show that you bilaterally performed this usually unilateral component.

Alternatively, some payers require you to report these services as follows:

• 92136-26-RT and 92136-26-LT.