Ophthalmology and Optometry Coding Alert

When an ophthalmologist performs a particularly difficult complicated cataract extraction -- one that requires a vitrectomy, for instance -- he's often attracted by the high relative value units (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 using "devices or techniques not generally used in routine cataract surgery," this 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).

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

• Is the pupil miotic?

• Is the patient very young, and still in the amblyogenic developmental stage?

• Does the IOL need extra support, such as permanent intraocular sutures or capsular tension rings?

• Does the ophthalmologist use dye to help him visualize the anterior chamber?

If the answers are "yes," you may be able to report 66982 instead of the lower-reimbursing 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis ...) for an extracapsular cataract removal.

Payment for 66982, based on the unadjusted national Medicare Physician Fee Schedule and the 2008 conversion factor (38.0870), is about $947, compared to $673 for 66984.

Watch out: Don't report 66982 just because the ophthalmologist encounters a surgical complication, such as the need to perform a vitrectomy. A true complex cataract extraction is prospectively planned based on pre-existing conditions.

Bottom line: Report 66982 only if the ophthalmologist knows preoperatively that a more complex procedure is necessary and meets the requirements of the code descriptor, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla.

Documentation in the medical record prior to the surgery will support this decision.