Ophthalmology and Optometry Coding Alert

Heed these documentation and modifier tips to ethically earn an extra $160 for after-cataract services.

Ophthalmologists perform thousands of cataract surgeries each year, which can lead to a fair share of post-op complications that can be difficult to code. Fair reimbursement for postoperative procedures for complications -- such as after-cataracts -- depends on the direction that follows on airtight documentation and skillful modifier use.

Beware PCO Within Global

The problem: Posterior capsule opacification (PCO), also known as an "after-cataract," is one of the most common problems following cataract surgery; a report from the Surgeon General found that 41 percent of patients develop PCO within 48 months after cataract surgery. In PCO, residual lens epithelial cells, left behind during the original surgery, proliferate and migrate. The membrane behind the new inserted intraocular lens thickens, blurring the vision.

Diagnosis: ICD-9 code 366.53 (After-cataract, obscuring vision).

(Note: This diagnosis code will change with ICD-10 -- see the "ICD-10" bridge following this article.)

Treatment: To treat after-cataracts, ophthalmologists incise the posterior capsule with an yttrium aluminum garnet (YAG) laser, allowing the capsule to contract and stop obstructing the passage of light to the retina.

Key: After-cataracts develop slowly, with most patients not noticing blurred vision right away, since they have experienced such improved vision from the cataract surgery, say experts. Many patients will not mention a complaint of blurred or decreased vision until cataract surgery is performed on the fellow eye and they notice the distinct difference in the clarity of their vision.

Cataract surgery procedures -- including 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique, complex, requiring devices or techniques not generally used in routine cataract surgery or performed on patients in the amblyogenic developmental stage), 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis [one stage procedure]) and 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique) -- have 90-day global surgical periods, so coding YAG procedures for the majority of patients is straightforward.

Report 66821 (Discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [e.g., YAG laser] [one or more stages]) and link it to 366.53. No modifiers are necessary if the YAG procedure takes place more than 90 days after the original cataract surgery and the patient is not within a post-operative period for any other surgical procedure performed by your physician or group.

Document Necessity for OR Returns

Ophthalmologists sometimes treat after-cataracts within the global period of the initial cataract surgery. In these cases, append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to 66821 to break it from the 6698x global surgical packages. (A laser suite in the ophthalmologist's office fits within Medicare's definition of "operating room.")

Some carriers are reluctant to pay 66821 claims within 90 days after cataract surgery and have local coverage policies that discuss when it would be appropriate to perform the procedure, so be prepared to prove medical necessity. For example, Medicare Part B carrier Palmetto GBA states: "This procedure is seldom indicated in less than three months post cataract surgery. If a claim is submitted for procedure 66821 within three months of cataract surgery, additional documentation will be requested."

Catch: Even if you have documented the medical necessity of performing the YAG laser capsulotomy within 90 days of the initial cataract surgery, be prepared to lose 30 percent of the normal reimbursement. "When a return to the OR is needed during the global period, modifier 78 is used to show that it was due to complications," explains Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Hospital & Network Oversight, Mount Sinai Medical Center Compliance Department in New York City. "Modifier 78 stipulates that a new global period should not start, as the surgery is considered part of the post op care. Therefore, only the intraoperative payment portion will be payable. The pre- and post-op period remain as is for the initial procedure."

As Chapter 12, Section 40.4.C of the Medicare Claims Processing Manual confirms, "When a CPT® code billed with modifier 78 describes the services involving a return trip to the operating room to deal with complications, carriers pay the value of the intra-operative services of the code that describes the treatment of the complications."

Translation: When the ophthalmologist performs a YAG capsulotomy within the global of cataract surgery, Medicare will not pay for the pre- and postoperative portion of the YAG procedure. The pre- and postoperative payment portion of the original cataract surgery, Medicare says, covers those services.

Therefore, the surgeon is only paid the interoperative allowance attributed to the fee schedule since they are considered to have already been paid for the preoperative and postoperative portions, given that the global period stays the consistent with the original surgery, clarifies Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Here's the payoff: The intraoperative portion of the global surgical package for 66821 is valued at 70 percent of the total RVUs (the pre-op is worth 10 percent, and the post-op is worth 20 percent). Based on Medicare's payment rule, if you bill 66821-78 performed in the hospital, you will be allowed $161 (70 percent of 8.74 RVUs = 6.12; multiplied by the 33.9764 conversion factor = $207.94, unadjusted for location) instead of the full $296.95 reimbursement.

Bill 66821 Once for Multiple Sessions

What if the patient had cataract surgery two years ago on the left eye, then had cataracts removed from the right eye last month -- and then presented with a complaint related to after-cataracts in the left eye? It's within the global for the surgery on the right eye, but since the after-cataracts are in the left eye, it's not related to the latest surgery.

Report 66821 appended with modifiers 79 (Unrelated procedure or service by the same physician during the postoperative period) and LT (Left side) to show that this new procedure is not connected with the most recent cataract surgery.

You have even more problems if the after-cataract takes more than one session to clear up. The phrase "one or more stages" appears in the description of 66821 and most other laser codes. This means you can only bill one laser procedure of the same code in a 90-day period on the same eye, because these codes are defined as for one or more treatments.