Ophthalmology and Optometry Coding Alert

When CMS recognized the new CPT code for complex cataract surgery, 66982, its intention was to simplify cataract coding, not make it more confusing. Unfortunately, frequent claims denials for 66982 tell another story.

The trouble with 66982 stems from surgeons' personal definitions of "complex," which don't always correspond to CPT's definition.

CPT 2002 defines complex cataract surgery as "extracapsular cataract removal requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary capsulorrhexis) or performed on patients in the amblyogenic development stage."

To coders' chagrin, surgeons sometimes deem cataract surgeries complicated for reasons such as increased time spent performing the procedure. "Cases that simply require more time are not necessarily considered complex," says Kevin J. Corcoran, COE, CPC, FNAO, a reimbursement and coding consultant, to Ophthalmology Times. "Also, some cases that required unplanned anterior vitrectomy due to a surgical misadventure are not complex."

Being able to correctly identify and code 66982 is a valuable skill though, considering the discrepancy in Medicare reimbursements for routine cataract surgery and complex cataract surgery. In 2002, the national Medicare reimbursement for a complex cataract procedure is $845.98, whereas Medicare values a routine cataract procedure at $669.32, an approximate 21 percent difference. And there is no ceiling on the number of complex cataract procedures you can be paid for, Corcoran says. "Medicare believe that this code [66982] should be used in approximately 1 percent to 2 percent of cataract surgeries," he says. But, he adds, "if you are referred a lot of patients with extraordinary situations, that number may be higher."

If a surgeon were not to be reimbursed because a typical cataract surgery, such as 66984, took longer to perform than normal, this service can be represented by modifier -22 (Unusual procedural services) for "greater service." The use of the -22 modifier requires that the claim be sent with an operative report and a note explaining why the service should be considered greater. It is also recommended to give a hint to the carrier of how much greater the service is.

For example, you may describe to the payer in your cover letter that the procedure took "twice as long" or required 50 percent more of the physician's time, says Raequell Duran, president of Practice Solutions, an ophthalmology coding and reimbursement consultancy. The key to this code, 66982, is that the surgeon knows ahead of time that the procedure will be complex and this is documented in the operative note, Corcoran tells coders.