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August 2013

 
Savvy Coder: Coding & Reimbursement
7 Challenging Cataract Cases
By Kristin Carter, MD, Academy Health Policy Committee, and Sue Vicchrilli, COT, OCS, Academy Coding Executive
 
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(PDF 53 KB)

What sort of cases stump cataract coders? The ones below were cited by the audience during Comprehensive Cataract Coding, a popular course at the Annual Meeting. (To learn about 2013 courses, scroll to Program Search at www.aao.org/2013 and select “Practice Management—Coding & Reimbursement” from the Topic menu.)

Tackle These 7 Cases

Q1. For the convenience of the patient, a cataract extraction from her right eye is accompanied by pterygium excision with graft. The National Correct Coding Initiative (NCCI) bundles the two procedures. Is there any way to get paid correctly for both?

Q2. During the global period of cataract surgery on the right eye, the surgeon repositions an IOL with McCannel suture. How is this coded?

Q3. During the same cataract extraction with IOL, a limbal relaxing incision (LRI) is performed to correct astigmatism that was not induced by previous surgery or trauma. What code is used for the LRI?

Q4. What code is used for a high-myopic patient who chooses to undergo a clear lens exchange?

Q5. What code is used for the removal of an implantable contact lens at the same surgical session as the cataract surgery?

Q6. The surgeon removes the natural lens but is unable to insert an IOL. Should this be coded as 66984–53, indicating a discontinued cataract extraction with IOL surgery?

Q7. What code is used for a piggyback IOL procedure in which two IOLs are inserted at the same session?

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Answers

1. Yes. Under NCCI, CPT code 65426 Excision of pterygium with graft is bundled with 66984 Cataract extraction with IOL. Submit 66984–RT and 65426–59–RT. By appending modifier –59, which indicates a separate procedure, both procedures should be paid.

2. Submit CPT code 66825–78–RT Repositioning of an IOL only, as it has the higher allowable. Modifier –78 indicates an unplanned return to the ASC. Payment is 80 percent of the allowable. Continue the 90-day global period of the cataract surgery. CPT code 66682 for the McCannel suture is bundled with the repositioning, and it would be inappropriate to unbundle.

3. There is not a level 1 CPT code other than the unlisted procedure, 66999 Unlisted procedure, anterior segment of eye. Because this is not a benefit covered by insurance, the patient is responsible for payment. There is no need to obtain an Advance Beneficiary Notice (ABN) from the Medicare Part B patient. It is, however, a very good idea to have a written policy describing the procedure and why patients are responsible for payment.

4. There is no CPT code other than the miscellaneous code 66999. Some practices create their own internal code. The patient would be responsible for all physician and facility charges. An ABN for the Medicare Part B patient is not necessary. It would be best to have an internal document developed that describes the charges for which the patient is responsible.

5. Submit CPT codes 65920 Removal of implanted material, anterior segment of eye and 66984 Cataract extraction with IOL. The codes should be billed with the highest allowed amount submitted first. The order of codes may vary by payer allowable. Payment will be 100 percent of the highest allowable and 50 percent of the lower one, due to multiple procedure reduction rules.

6. A better option is to submit for the work completed, using CPT code 66850 Removal of lens material; phacofragmentation technique. At a later date when an IOL is implanted, submit 66985–58, indicating that the insertion of a secondary IOL was planned for that later date.

7. Submit 66984 Cataract extraction with IOL only.

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