Ophthalmology and Optometry Coding Alert

Confusion persists regarding 66982, the new code for complicated cataract surgery. Some ophthalmologists want to use the code, which reimburses almost $1,000, for any cataract surgery they deem to be complicated. But if they follow their own coding philosophy, and not official rules, they risk charges of abusive and possibly even fraudulent billing. They also put the codes future in jeopardy. HCFA may eliminate coverage for the code if ophthalmologists misuse it.

CPT says to use 66982 for cataract surgery that requires devices or techniques not generally used in routine cataract surgery, and goes on to give examples. But a groundswell of opinion among many ophthalmologists and coders holds that the examples in CPT are just that: examples.

The descriptor for 66982 says e.g. (for example), not i.e. (that is) before giving the examples. Therefore, many ophthalmologists believe they can use the high-paying code for more than the examples given, which are:

1. iris expansion device;
2. suture support for intraocular lens;
3. endocapsular rings; or
4. primary posterior capsulorrhexis.

Not for Vitrectomies

Ophthalmologists have many other examples of what they consider to be complicated cataract surgery. Ophthalmologists must sometimes perform anterior vitrectomies (67005-67010) as a part of cataract surgery to remove vitreous from the anterior chamber when, for example, the cataract is very dense, causing vitreous loss during the surgery. The ophthalmologist performs the vitrectomy to manage a complication of the cataract surgery.

The CPT descriptor for 66982 does not mention or prohibit its use for a complication, says Michael Yaros, MD, a solo practitioner in Runnemede, N.J. The CPT descriptor likewise doesnt limit the use to the scenarios listed. But you should never use 66982 for cataract surgery performed with an anterior vitrectomy. Most of the time, you should not even bill a regular cataract code with an anterior vitrectomy.

Codes 67005 and 67010 are listed as components of 66984 (extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]) on the Correct Coding Initiative (CCI) and are not separately payable for iatrogenic complications. The billing of 66984 and 67005 or 67010 with modifier -59 (distinct procedural service) would be unbundling, a type of Medicare billing fraud, says Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based ophthalmology coding and compliance consultancy.

Nine out of 10 times, the need for anterior vitrectomy is an iatrogenic complication of the cataract surgery, says Lise Roberts, vice president of Health Care Compliance Strategies, an interactive compliance training company based in Syosset, N.Y. Carriers dont want to make extra payments for complicated cataract surgeries when the reason for the complication is the surgery itself.

The vitrectomy is bundled into the cataract procedure because it is usually incidental to the surgery. The only way to bill for a vitrectomy and cataract surgery done during the same session is with a -59 modifier, and you must have a separate reason for each, such as a pre-existing vitreal prolapse.

Some coders want to bill 66984-22 (unusual procedural services) for certain kinds of cataracts that also require anterior vitrectomies, such as senile cataract, patient lack of cooperation, or adhesions. Patients wait too long for the surgery to be done, and in the process of getting the cataract out the vitreous collapses and needs to be repaired. But vitreous loss in the course of performing cataract surgery that did not exist prior to the procedure is included in the cataract extraction code, Roberts says.

Code 66982 has nothing to do with a prolapsed vitreous, stresses Sue Vicchrilli, COT, education program manager with the practice management department at the American Academy of Ophthalmology (AAO).

Medicare fees recognize that some cataract cases that fall in the normal range will be easy whereas others will require more work. HCFA considers this the law of averages and has set the unit values for the work to reflect an expected normal range of difficulty. That range includes the performance of anterior vitrectomy when there is vitreous loss in the course of cataract surgery.

If a prolapsed vitreous exists prior to performance of the cataract surgery and is not a complication of the surgery, an ophthalmologist could plan in advance to perform a vitrectomy during the same session as cataract surgery. But do not code that as a complicated cataract procedure (66982). Instead, bill the cataract surgery code and the anterior mechanical vitrectomy code (67010) with modifier -59 to identify it as a distinct surgical procedure.

Tip: Many ophthalmology coders make the mistake of using subluxed lens (the cause of the prolapse) as the diagnosis on the vitrectomy done with cataract surgery. Link subluxed lens (379.3x) to the cataract procedure code. Use vitreal prolapse (379.26) for the vitrectomy.

Knowledge In Advance

Some coders say they would never use 66982 unless the physician knew in advance that he or she would need to perform complicated cataract surgery. Requiring that a physician know in advance that he or she must use 66982 sends a good message about how ophthalmologists should use this code, Roberts says.

An in-advance guideline makes sense, agrees Michael X. Repka, MD, the AAO advisor to the AMA CPT Advisory Committee. But he cautions against making it an absolute requirement. There may be times when 66982 would be justified, but the physician wouldnt know that until getting to the operating room. I certainly wouldnt want to make that the only guideline, he emphasizes.

66982 Is Not for All Complicated Cataract Surgery

In addition to anterior vitrectomies done for a prolapsed vitreous, there are many examples of cataract surgery for which ophthalmologists would like to bill 66982 but shouldnt, at least for now. These include the following.

Pseudoexfoliation: A patient has a pseudoexfoliation, a condition of the connective tissue that can clog the structures in the angle of the eye. At its worst, pseudoexfoliation can make cataract extraction more difficult because the zonules that hold the capsule that houses the cataract and keeps the vitreous in the posterior chamber are weak, Yaros explains. The weak zonules make it difficult to get the cataract out without losing vitreous. The vitrectomy must be performed to remove the vitreous that escapes into the anterior chamber, but it is more than a vitrectomy. Nevertheless, this case would not merit 66982. This vitrectomy is included in the cataract surgery code.

Capsular staining: Some ophthalmologists want to use 66982 for a procedure using indocyanine green (ICG) dye. The dye stains the capsule blue, so the ophthalmologist can perform a clearly visible capsulotomy on a white cataract that otherwise makes it difficult to see where the capsule is, Yaros explains. The staining method meets the definition of a procedure not ordinarily used in cataract surgery, Yaros says. But just because something is not ordinarily used in cataract surgery doesnt mean it qualifies for 66982.

Also, the Food and Drug Administration (FDA) has not approved capsular staining, therefore Medicare does not cover it, Roberts says. Billing it as a complicated cataract and collecting the extra fee allowance would be misrepresenting a noncovered service as a covered service. This falls into the definition of fraud. If this technique becomes an FDA-approved application, the complicated cataract surgery could become applicable.

Piggyback implants: Another indication for 66982, some physicians say, is the piggyback IOL. This method involves a second (additional) implant used at the time of cataract surgery. There is additional work effort used in implanting the second implant, not otherwise reimbursed, Yaros says. But again, just because there is additional work doesnt necessarily mean you can use 66982.

The 2-percent Threshold

HCFA has determined that it will target for audit any physician coding 66982 for more than 2 percent of his or her cataract surgeries. If you treat many glaucoma patients, or are in a teaching institution with many complicated cases, your volume may exceed that threshold legitimately. You would then be a possible audit target.

We expected glaucoma specialists to use this code, Repka says, because glaucoma is often treated with pilocarpine, a drug that makes the pupil smaller. Small pupils make cataract surgery difficult because the physician cant get to the lens without expanding the iris, hence the reference to iris expansion devices in the code descriptors.

If a patient has a small pupil because of pilocarpine use, an iris retraction device is one way to access the back of the eye for lens removal and IOL insertion. Another method, not specifically mentioned in the 66982 descriptor, is making an incision in the iris. This incision would qualify as a technique not generally used in routine cataract surgery and would justify the use of 66982, Repka says.

The Claim Form and Audits

When you file 66982, you dont put your operative note on the claim form. The payer wont know whether you are meeting the requirements of the CPT descriptor, which specifies how this cataract procedure is performed, unless it audits you.

Carriers will be monitoring the usage of 66982 closely, Roberts says. If a physician stands out as having more than 2 percent of total cataract volume represented by 66982, that physician will very likely be audited. The auditor will look for an operative note reflecting not only extra work but also the specific extra work designated by the code. Work described that is not designated by the code will likely have to be defended as representing complicated surgery. Remember that treatment must be reasonable and necessary to be valid, not experimental (non-FDA-approved off-label uses), Roberts says.

Unbundling

The AAO and the American Society of Cataract & Refractive Surgery (ASCRS) are working out exactly what 66982 can and, more important, cant be used for. In the meantime, if you are billing Medicare and your carrier is BC Kansas, you have a local medical review policy (LMRP) that tells you how to use the code. And if you dont have an LMRP, you have CPT.

Most ophthalmologists have only CPT to go by. If there were a national policy, we would follow that, says Gilda Edelstein, practice administrator for Medical Eye Care Associates, a 13-physician practice in Norwood, Mass. As a general rule, you do what the national policy says. Until there is clear guidance from someone regarding how to use 66982, Edelstein is taking the conservative approach: not billing it.

Its true that if CPT had limited the use of 66982 to the examples it provides, the code descriptor would not create such confusion. But keeping the definition broad by using examples instead of limiting scenarios allows for the inclusion of new techniques without rewriting the code.

It is now up to carriers to further define 66982. One carrier, Blue Cross and Blue Shield (BC/BS) of Kansas, did so on April 15. (See box on page 44.) Try to follow the intent of CCI. The BC/BS Kansas policy states that 66982 should not be used to avoid the tenets of the Correct Coding Initiative. It would make sense for CCI to bundle at least what is now bundled in 66984 into 66982.

Billing for ASC Use

HCFA will approve 66982 for ambulatory surgical center (ASC) use. The process is under way. Approval will be retroactive to Jan. 1, 2001. Therefore, if you perform 66982 in an ASC prior to approval, and your claim is denied, keep the denial and refile when HCFA releases the program memorandum.

Another way to bill for ASC use is to code 66982 for the physician, and 66984 for the facility. However, carriers may still reject the claim because the facility and physician codes dont match, and you would have to refile. Code 66982 is in the highest-paying ASC category, as is 66984. The fees are the same: $942. The cost of the IOL is included in the fee.