Ophthalmology and Optometry Coding Alert

Question: My ophthalmologist began a phacofragmentation cataract surgery with intraocular lens (IOL) insertion but had to discontinue the procedure. How can I report this to ensure we get paid for the time spent in surgery, but don't violate any correct coding regulations that will set us up for fraud investigations?


Michigan Subscriber

Answer: The answer depends on how much of the procedure your ophthalmologist was able to perform and why he had to discontinue the surgery.

Option 1: If the ophthalmologist administered sedation and began the surgery but had to stop because of extenuating circumstances that put the patient's health in jeopardy, you'll report the surgical code and append modifier 53 (Discontinued procedure).

Example: The patient is sedated, then the surgeon performs a retrobulbar block, makes the incision and starts removing the cataract, but the patient starts moving on the table. Increasing the level of IV sedation is ineffective, so the surgeon discontinues the procedure. In this case, you should report 66984-53 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]).

Tip: If your ophthalmologist returns to the operating room within the 90-day global to finish what he started, report 66984 again, but append modifier 78 (Return to the operating room for a related procedure during the postoperative period).

Option 2: If the physician was able to complete the removal of the cataract but not the insertion of the IOL, you'll report another code entirely. Since there's a procedure code to describe that procedure, 66850 (Removal of lens material; phacofragmentation technique [mechanical or ultrasonic] [e.g., phacoemulsification], with aspiration), you should report 66850 with RT (Right side) or LT (Left side) instead of the code for the procedure that was originally intended (66984).

Next: When the physician brings the patient back to insert the IOL, you would report 66985 (Insertion of intraocular lens prosthesis [secondary implant], not associated with concurrent cataract removal) with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period).

Key: Your physician should note all procedures performed including the retrobulbar block and any incisions or other work that he performed. That documentation will determine how you report the procedure, and your carrier may want to review it if you do submit your claim with modifier 53.

Remember: Documentation is very important when you're reporting discontinued procedures and the return to the operating room (OR) to complete a procedure. The operative report should include information as to why the ophthalmologist terminated the procedure, how much work he performed prior to discontinuation of the procedure (e.g., 45 percent) and any complications or other extenuating circumstances that may have occurred.

When the patient is brought back to the OR, the op report should reiterate the prior circumstances and need for return to the OR to complete the surgery.