Ophthalmology and Optometry Coding Alert

The AMA has issued a new code for complicated cataract surgery for CPT 2001 66982 (extracapsular cataract removal with insertion of intraocular lens prosthesis [one 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, endocapsular rings, or primary posterior capsulorrhexis] or performed on patients in the amblyogenic developmental stage). This code should be used instead 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]) in cases of complex cataract surgery.

In the November 2000 issue of Ophthalmology Coding Alert we stated that the code would be used in three circumstances: the amblyopic period, in a patient with a history of a subluxated lens, or in a patient with miotic pupils due to glaucoma medication. The final recommendations for Medicare payment policies have changed. CPT does not specify the circumstances that allow the new code. HCFA and the American Academy of Ophthalmology (AAO) worked out the recommendations during the last days of October. These recommendations will be included in a model policy and circulated for Medicare carriers to follow. How private payers will treat the complex cataract surgery code is unclear at this time.

The new code will be used for the more complex situations, notes Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based coding and compliance consulting company specializing in ophthalmology. Some of those situations are:

use of an iris expansion device,
suture support or intraocular lens,
endocapsular rings,
primary posterior capsulorrhexis, and
patients in the amblyogenic stage of development.

Reimbursement for 66982 is expected to be substantially higher than for 66984. The Medicare fee schedule with RVUs is expected soon.

These recommendations are included in the code descriptor as an example, but they are not all-inclusive. A payer may reimburse for this code for other indications CPT cannot list them all. CPT is appropriately vague, notes Michael X. Repka, MD, the AAOs representative to the AMA CPT advisory committee. For example, CPT does not specify using the code for a patient with miotic pupils due to glaucoma medication. But it does specify an iris expansion device. Therefore, if you place a device to stretch the iris in a patient with miotic pupils, you could be paid for the extra work involved, Repka says. But 66982 isnt just for stretching the iris with a hook. Other devices may be used.

The additional payment for a complicated case is for the additional, significant work that is involved. It is important that physicians using 66982 document the additional work in operative reports. When this new code is used during the first few months of 2001, there will be variations on how payers handle payment. Payers may request documentation prior to payment, deny payments, or pay inappropriately low amounts that will be appealed. In these cases, good documentation of the procedures complexity can resolve the problem.