Ophthalmology and Optometry Coding Alert

Question: When our retina surgeon performs a lensectomy with insertion of an intraocular lens (IOL), what is the correct coding?

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Answer: You’ll need further clarification from the operative report to confirm which of these options is most appropriate.

For cases in which the retina specialist removes the natural lens and inserts an IOL prosthesis, start by determining whether the surgery qualifies as a complicated extraction. If it meets the requirements outlined in the code descriptor, report 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis … complex… without endoscopic cyclophotocoagulation).

If the surgery is performed in a single session and isn’t considered a complicated extraction, then you’ll code the procedure according to the technique and approach used:

For an intracapsular removal, you should report 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)).

For an extracapsular removal report 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation).

In the event the procedures are performed in two separate sessions — the lensectomy on one day and the IOL insertion on another day — code each trip to the operating room (OR) separately. Choose between the following codes for the initial lens removal depending on the surgeon’s technique or approach:

• 66840 (Removal of lens material; aspiration technique, 1 or more stages);
• 66850 (… phacofragmentation technique … with aspiration);
• 66852 (… pars plana approach …);
• 66930 (… intracapsular, for dislocated lens); or
• 66940 (… extracapsular …).

Code the staged return to the OR for the insertion of the secondary IOL using 66985 (Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal) and append modifier 58 (Staged or related procedure or service by the same physician … during the postoperative period). Take care to document the medical necessity of staging these procedures rather than performing them together.

When your retina surgeon removes and replaces a dislocated IOL, in addition to a pars plana vitrectomy, report 66986 (Exchange of intraocular lens) for the IOL exchange and 67036 (Vitrectomy, mechanical, pars plana approach) for the pars plana vitrectomy.