Wiki Complex Cataract surgery

[CBP2014]

My employer/practice is ophthalmology - we have 3 surgeons out of 5 providers (6th starting in October). They had an outside billing group for many years, but brought back in-house in 2021. The administration has decided on an internal audit of all complex cataract cases for the last 18 months.
Our billing/coding department tis small, I am the only coder with 3 additional billing staff.
I know the guidelines on what qualifies as complex but I am looking for best practices on confirming complex coding is applicable.
Do you rely on physician's operative note as primary source?
Do you review informed consents?
Do you review pre-op visit documentation for planned complex situation?
What is your process?
Thank you in advance.

 

[natashalage]

Hello, I am a medical coder and one of my specialties is Ophthalmology; however, I am still learning and I obtained COPC. We code surgery only from the Op notes! dx, date, signature- all requirements are there. we don't go outside the Op note. The description of the procedure determines whether it was a simple or complex cataract surgery: 66984-simple and 66982-complex. Of course, there are combination codes for cataract Sx and insertion of iStent and cyclophotocoagulation.

 

[Edmundo]

Hello CBP2014! It's a pleasure.

Great question! Determining a complex cataract case depends within your contractor. Please reference both these articles & confirm your jurisdiction - again guidelines vary.

I'm in jurisdiction JH. One of the following below is what we consider a cataract case to be complex.

1. A miotic pupil that will not dilate sufficiently4 requirng the use of a mechanical iris expansion device (Iris retractors through four additional incisions, Beehler expansion device, or Malyugin ring) to adequately visualize the lens in the posterior chamber of the eye.4
2. Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens.5
3. Pediatric cataract surgery, intraoperatively difficult because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove needing a primary posterior capsulotomy or capsulorrhexis.
4. Mature cataract requiring dye for visualization of capsulorrhexis.

Article - Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (A58592) (cms.gov)

LCD - Cataract Extraction (including Complex Cataract Surgery) (L35091) (cms.gov)


Yes, the physician's operative report is the primary source.

Personally as a coder, I do not review informed consents.

Hope this answers all your questions! Best of luck in ophthalmology!


Edmundo Gonzalez, CPC, COPC

 

[ambermeade]

@Edmundo are there specific ICD-10 codes you look for in obtaining number 4 on your list for a mature cataract?

 

[Edmundo]

Hi @ambermeade

Great question! According to the American Academy of Ophthalmology, these are the list of ICD10CM codes that are considered to be mature cataract:

• H25.21 Age-related cataract, morgagnian type (hypermature) right eye, H25.22 left eye, or H25.23 bilateral;
• H25.811 Combined forms of age-related cataract right eye, H25.812 left eye, or H25.813 bilateral;
• H25.89 Other age-related cataract.

Edmundo Gonzalez, CPC, COPC, OCS

 

[ambermeade]

Hi @ambermeade

Great question! According to the American Academy of Ophthalmology, these are the list of ICD10CM codes that are considered to be mature cataract:

• H25.21 Age-related cataract, morgagnian type (hypermature) right eye, H25.22 left eye, or H25.23 bilateral;
• H25.811 Combined forms of age-related cataract right eye, H25.812 left eye, or H25.813 bilateral;
• H25.89 Other age-related cataract.

Edmundo Gonzalez, CPC, COPC, OCS

Thank you for this information.

 

[billing@osandp.com]

Hello CBP2014! It's a pleasure.

Great question! Determining a complex cataract case depends within your contractor. Please reference both these articles & confirm your jurisdiction - again guidelines vary.

I'm in jurisdiction JH. One of the following below is what we consider a cataract case to be complex.

1. A miotic pupil that will not dilate sufficiently4 requirng the use of a mechanical iris expansion device (Iris retractors through four additional incisions, Beehler expansion device, or Malyugin ring) to adequately visualize the lens in the posterior chamber of the eye.4
2. Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens.5
3. Pediatric cataract surgery, intraoperatively difficult because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove needing a primary posterior capsulotomy or capsulorrhexis.
4. Mature cataract requiring dye for visualization of capsulorrhexis.

Article - Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (A58592) (cms.gov)

LCD - Cataract Extraction (including Complex Cataract Surgery) (L35091) (cms.gov)


Yes, the physician's operative report is the primary source.

Personally as a coder, I do not review informed consents.

Hope this answers all your questions! Best of luck in ophthalmology!


Edmundo Gonzalez, CPC, COPC

Do you know what combination codes for cataract Sx include? Is it listed somewhere?

 

[natashalage]

Hello, I am not an expert but since nobody answered, I will try. Combination codes for cataract? They are 66989 and 66991- with iStent, 66987 and 66988 with cyclophotocoagulation. If you have other procedures performed, i would use Encoder etc to see if there is a bundling issue. You can also read NCCI file for ophthalmology chapter that also tells you what is included with cataract like injections.
I am ready to learn more.