Ophthalmology and Optometry Coding Alert

Coding IOL procedures can be tricky - and errors can cost you more than $800

If your ophthalmologist inserts an intraocular lens (IOL) prosthesis after a pars plana partial vitrectomy and removal of a dislocated lens, don't count on a single CPT code to get reimbursed for all of the work.

To get paid for that IOL insertion - and for other complex procedures like lens repositionings and piggyback lens insertions - you'll need a strong grasp of the CPT code descriptions and modifiers. Our experts help you find your way through several difficult IOL scenarios.

Dislocated Lens Replacement

Scenario: The ophthalmologist removes a dislocated natural lens and places an IOL prosthesis.

Solution: IOL insertion is included in the cataract removal codes, says Sheila Cutler, patient information supervisor for the department of ophthalmology at the University of Kansas Medical Center in Kansas City. Code the procedure according to the technique and approach used.

If the procedure meets one of the criteria for a complicated cataract extraction, report 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-step 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), Cutler says.

If the procedure is not a complicated extraction and is performed in a single session, for an intracapsular removal you should report 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis [one-stage procedure]), Cutler says, or for an extracapsular removal report 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]).

If the procedure is performed in two sessions - the lens removal on one day and the lens insertion on another day - report 66930 (Removal of lens material; intracapsular, for dislocated lens) for the day the dislocated lens is removed, and 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) appended for the day the IOL is placed, Cutler says.

IOL Following Lens Removal and Minor Vitrectomy

Scenario: The ophthalmologist removed a dislocated lens through a pars plana approach, performing a minor posterior vitrectomy to aid in the lens removal. He also inserted an IOL.

Solution: For the lens removal, you might immediately think of CPT code 66852 (Removal of lens material; pars plana approach, with or without vitrectomy). The problem is that code doesn't accurately describe all the work performed - 66852 doesn't mention the IOL.

To fully describe the work done, you'll have to use an additional code, says Delinda Fields, patient account billing manager for the Maple Grove Eye Clinic in Boise, Idaho.

Depending on the documentation of the surgery, you can bill 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis [one-stage procedure]) or 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure]), Fields says. List 66852 first because it carries more RVUs than 66983 or 66984.

Append modifier -59 (Distinct procedural service) to 66983 or 66984, Fields says, to show that the cataract extraction is distinct from the vitrectomy.

Another option: Code the vitrectomy 67036 (Vitrectomy, mechanical, pars plana approach) and append modifier -52 (Reduced services) to indicate that the ophthalmologist did not perform all the work represented in the CPT description. Then report code 66983 or 66984, appending modifier -51 (Multiple procedures), to indicate to the insurer that the procedure should receive the multiple- procedure reduction.

Repositioning of IOL

Scenario: After cataract surgery and IOL insertion (66984), the patient falls and bumps his head. The IOL is jarred loose and needs repositioning.

Solution: ""If I had cataract surgery done, and a month later I need to have [the IOL] repositioned in the same eye, it's a return trip to the operating room,"" says Diahanne Spooner, CPC, director of compliance for the Mid-Florida Eye Center in Mt. Dora.

If the IOL repositioning is necessary due to complications after the cataract surgery, report 66825 (Repositioning of intraocular lens prosthesis, requiring an incision [separate procedure]) and append modifier -78 (Return to the operating room for a related procedure during the postoperative period), Spooner says.

If, however, the initial procedure was not related to the IOL insertion, and a pre-existing IOL needed repositioning - or if the IOL in question is in a different eye from the one that had the previous surgery - report 66825 and add modifier -79 (Unrelated procedure or service by the same physician during the postoperative period), Spooner says.

She adds that her practice doesn't always bill for IOL repositioning. ""We just fix it,"" she says. ""Unless they're in a major trauma, we usually just don't charge the patient for it.""

The diagnosis code for the repositioning is 996.53 (Mechanical complications of other specified prosthetic device, implant, and graft; due to ocular lens prosthesis).

Piggyback IOL

Scenario: The ophthalmologist performs a piggyback IOL with bilateral cataract removal.

Solution: Resist the urge to report 66984 and 66985 together, Fields says - NCCI bundles those two codes as mutually exclusive. If the piggyback IOL is inserted concurrent with cataract surgery, look to code 66982.

If the piggyback IOL insertion is a separate procedure, the rules change. ""If you've already removed the cataract and put an implant in, and now you're taking out that implant and putting a secondary implant in,"" Fields says, 66982 would not apply because it describes a cataract removal. In that case, she says, 66985 is the correct code to report.

Another option: Report the bilateral cataract removal with 66984, and append modifiers -22 (Unusual procedural services) and -50 (Bilateral procedure) to indicate the extra work that the ophthalmologist performed on both eyes. This may require documentation to support the additional work, but some may think that 66984-22-50 more accurately describes the procedure than 66982.

Discontinued IOL Procedure Due to Complications

Scenario: The ophthalmologist performs a cataract extraction IOL insertion (66984). The patient develops a vitreous bulge after the ophthalmologist has removed the cataract. Rather than risk vitreous loss, the ophthalmologist decides against inserting the IOL in this session.

Solution: For the initial procedure, Cutler says, bill 66984 and append modifier -53 (Discontinued procedure) to indicate that the full procedure was not done.

When the ophthalmologist finishes the procedure, report 66985 and append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period), she says. The documentation for 66984 should show that the ophthalmologist planned to insert the IOL later.