Ophthalmology and Optometry Coding Alert

Question: I have been receiving denials when I code 66984 and 66985 for a piggyback IOL with bilateral cataract removal. Am I forgetting a modifier? Why are my claims being denied?

Maryland Subscriber

Answer: According to CCI 8.2 effective July 1, procedure codes 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]) and 66985 (Insertion of intraocular lens prosthesis [secondary implant], not associated with concurrent cataract removal) are "mutually exclusive" codes, which means they can't be billed together unless they meet the criteria for modifier -59 (Distinct procedural service).

But according to the Coverage Issues Manual (65-7), intraocular lenses inserted during or subsequent to cataract surgery are payable separately when billed by a physician if payment has not been made to an ambulatory surgical center (ASC).

There is no indication that the piggyback IOL payment did not go to the ASC or that the second lens was inserted at a later date, which would justify coding 66985 because it would no longer be considered included in the cataract removal. Therefore, you do not have grounds for either a modifier or billing both codes at once. You should, however, code 66984-50 because the cataract surgery was bilateral.