Ophthalmology and Optometry Coding Alert

Question: A patient who underwent cataract extraction with intraocular lens (IOL) insertion (66982) 30 days ago returned to the ophthalmologist with complaints of elevated intraocular pressure (IOP). After evaluating the patient, the physician decided that the patient needed aqueous release to relieve the pressure. The patient returned to the procedure room the next day to undergo a paracentesis of the anterior chamber.

Can we report 65815 during the postoperative period?

Delaware Subscriber

Answer: Based on the information you’ve provided, you can report 65815 (Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without irrigation and/or air injection) to report the procedure during the post-op period.

In order to bill 65815 during the 90-day global period for 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation), the procedure must meet the following criteria:

• The patient is experiencing elevated IOP that requires aqueous release;
• The intervention is not routine and is medically necessary; and
• The physician performs the procedure in a procedure room or operating room (OR) setting.

Additionally, the provider’s documentation should indicate medical necessity for the paracentesis and include where the procedure occurred. For example, “Due to significantly elevated intraocular pressure that was not responsive to medical therapy, the patient was taken to the OR for anterior chamber paracentesis.”

Mike Shaughnessy, BA, CPC, Production Editor, AAPC