Wiki Cataract surgery with complications-please help!!

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katiejeanne

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I have a cataract surgery that I am struggling to code since there was a complication during surgery.
The provider used his normal cataract removal template and added the following to it:

"Towards the beginning of divide and conquer it was noted the inferonasal quadrant posterior capsule was not intact. Phacoemulsification performed until vitreous could no longer be pushed back with viscoat and vitreous was anterior. I then placed viscoat and anterior itrectomy performed with 600 (cutting?) rate. The CCC was intact. Healon placed followed by injection of MN60 PCIOL. The sulcus placed _____ centered the lens with capsular capture. I/A performed. Miostat placed."

Operative Procedures Performed: No-Stitch phacoemulsification with implantation of a foldable lens/Anterior Vitrectomy/PCIOL-sulcus with iris capture.
Complications: Posterior capsule rupture, vitreous loss.

I guess my question is, can I charge for anything but the cataract phacoemulsification/lens implant since that was the only thing that was originally planned? If so, what CPT would I use? The surgery department put on CPT 65810 and I'm unsure of that code...Thanks in advance!!!

Katie
 
Thanks for your reply. I thought of this one too, but I did some research on that and found an article from Ophthalmology Coding Alert, October 2004 that said otherwise. It states "Reporting 66982 just because of surgical complications could land you in deep trouble" and "Addressing complications during surgery does not make a cataract extraction complex". It goes on to say that you can't just use 66982 just because you had to do a vitrectomy, even though thats a technique you wouldn't normally use, you performed it because of a complication. A true complex cataract extraction has to be prompted by a pre-existing problem that requires something additional you have to do.

If the above is true, then how am I supposed to end up billing this? Any other thoughts on this?
 
I would code this 66984 due to the fact that the vitrectomy was not stated in the record prior to the surgery. It does not qualify as a complex surgery. I use 66982 when, prior to surgery the surgeon indicates a pupil dilation will be necessary, etc.
Hope this helps.
Sharon
 
66982 is incorrect. There is a specific list of criteria that needs to be met to be able to use 66982. Complications, things gone wrong, took longer than usual, etc. is not part of them.
 
The surgeon states that he did an "Anterior Vitrectomy. Bill 66984 and 67005-51 "Removal of vitreous, anterior approach (open sky technique or limbal incision; partial removal."

Debra Miller, COT, OCS, (CPC in training)
 
Cataract code would be 66984. No separate vitrectomy code. That is not billable unless it was planned in advance and the record is documented. Not billed when complication during surgery.
 
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