Ophthalmology and Optometry Coding Alert

Question: Lately, I've been getting denials for 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]) along with either 67005-59 (Removal of vitreous, anterior approach [open sky technique or limbal incision]; partial removal; distinct procedural service) or 67010-59 (... subtotal removal with mechanical vitrectomy; distinct procedural service). What might I be doing wrong?

Washington State Subscriber

Answer: The denials are coming because the codes are bundled. NCCI has bundled 67005 and 67010 into 66984 since 1996. In other words, the vitrectomy is a component (a necessary part) of the cataract surgery, and as such is not separately payable. (The American Academy of Ophthalmology tried several times to convince CMS otherwise, with no success.)

Ophthalmologists often have to perform a vitrectomy during the course of cataract surgery due to vitreous collapse in the course of removing a dense, senile cataract.

Medicare considers this to be an iatrogenic -- i.e., inadvertently introduced -- complication in the course of cataract surgery that is included in the payment for cataract removal.

However: If a prolapsed vitreous exists and is known in advance -- and documented in the patient medical record -- it is not considered a complication of the cataract surgery.

Therefore, the physician who plans to perform a vitrectomy during the same operative session of cataract surgery could bill separately for the vitrectomy using modifier -59 (Distinct procedural service): 67005-59 or 67010-59.

Key: Documentation and diagnosis codes can get you reimbursement. Use 379.26 (Vitreous prolapse) for the vitrectomy and the appropriate cataract diagnosis for the cataract removal.

Be prepared to provide documentation in case you receive denials when using these codes together, despite the use of modifier -59. The payer is undoubtedly aware of the potential for abuse of -59 and may want you to go through the review process to prove you've met the definition of "distinct procedural service."

Provide the chart notes and the operative report that shows that there was another condition, besides the cataract surgery, that made the vitrectomy medically necessary.