Ophthalmology and Optometry Coding Alert

Reporting 66982 just because of surgical complications could land you in deep trouble

When an ophthalmologist performs a particularly difficult complicated cataract extraction - one that requires a vitrectomy, for instance - he's often attracted by the high RVUs of the complex cataract code, 66982. But that code can be a trap, experts say, and can lead to costly denials, even audits.

Even if the ophthalmologist thinks he's employing "devices or techniques not generally used in routine cataract surgery," it doesn't automatically allow you to report 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, or primary posterior capsulorrhexis] or performed on patients in the amblyogenic developmental stage).

Insurers pay close attention to 66982 claims, says Christina Hollis, OCS, surgery scheduler at Pediatric Ophthalmology Associates in Columbus, Ohio. The code "is a target for audits," she says.

Our experts offer the following advice to help make sure you're not abusing 66982.

Know What Makes Extraction 'Complex'

Code 66982 "is not supposed to be used routinely," says Michael Yaros, MD, a practicing ophthalmologist based in Runnemede, N.J. Don't report it "just because the case took longer or was more difficult or involved a complication - none of those things matter," he says. What does matter is "whether or not you use a particular technique or instrumentation because of the nature of the procedure."

Ask yourself these questions when you're deciding whether to report 66982:

Is the pupil miotic? The most common factor necessitating a complex cataract removal, Yaros says, is the size of the pupil. If the pupil is too small, the ophthalmologist must use devices (iris retractors, for example) or techniques (sphincterotomies, for example) to gain access to perform the cataract removal. That would fit the description of the code, Yaros says.

Is the patient very young? "We use 66982 for kids who are 5 and under," Hollis says. "They're in the age range where they can still develop amblyopia, which is one of the examples that's listed [in the code description]."

Does the IOL need extra support? Blue Cross/Blue Shield of Kansas cites "a disease state that produces lens support structures that are abnormally weak or absent" as an indicator for 66982. If the ophthalmologist needs to support the IOL implant with permanent intraocular sutures, you may be able to report 66982. Ophthalmologists may also now use capsular tension rings, which the FDA approved in April 2004, to support the IOL.

Does the ophthalmologist use dye? If he injects ICD dye or some other form of dye to help him visualize the anterior chamber, it may back up your 66982 claim. In cases of mature cataracts or vitreous hemorrhage, "you can get a better capsulotomy with the use of the dye," Yaros says. Part B carrier TrailBlazer's LCD for 66982 specifically mentions "mature cataract requiring dye for visualization of capsulorrhexis" as an indication for the code.

Don't Report 66982 for Complications

Addressing complications during surgery does not make a cataract extraction complex, Yaros says. "You can't just use [66982] because you had to do a vitrectomy," he says. "Even though that's a technique you wouldn't normally use, you perform it because of a complication." A true complex cataract extraction has to be prompted by "a pre-existing problem that requires something additional you have to do," he says.

Do this: Report 66982 only if the ophthalmologist knows preoperatively that the procedure is necessary and meets the requirements of the code descriptor. "It should be prospectively planned that way," Yaros says.

Example: If the ophthalmologist notes in his preoperative report that the pupil seems small and may need to be expanded, it will help make your case for 66982. "I tend to add that to the preoperative notes anytime I think there might be a problem," Yaros says. If the pupil stretching is not preoperatively planned, "you probably shouldn't bill that as a complex cataract," Yaros says, even though the ophthalmologist is doing the same amount of work.