Ophthalmology and Optometry Coding Alert

Question:  Our ophthalmologist performed a cataract discission with sedation. We’re reporting 66821 for the surgery, but how should we report the sedation?

Codify Subscriber

Answer: The answer depends partly on where you perform the procedure. If the surgery is performed in an ambulatory surgery center (ASC), you should limit your coding to just 66821 (Discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [eg, YAG laser] [1 or more stages]). Sedation is included in the surgical package for this service when performed in the ASC, so you cannot separately report the sedation.

If you perform the service in a setting where the sedation is billable, you’ll look to the codes in the 99151-+99157 range. You’ll select the appropriate code based on age and time duration, using intraservice time to determine the appropriate CPT^® code. The time period starts with administration of the sedating agent(s) and ends when the procedure is completed with the end of personal continuous face-to-face time with the patient.