Unusual Cataract Cases: What Claim Would You Submit?

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Cataract surgery does not always go as planned. Would you know how to code for these surgical surprises?

Dropped Lens Was Referred

Surgery. A patient had a hypermature cataract in her right eye. During sur­gery, VisionBlue (trypan blue) was used for the capsulotomy, but some of the lens dropped. A mechanical anterior vitrectomy was performed, but no intraocular lens (IOL) was placed. The patient was referred to a retina special­ist for removal of the remaining lens material and IOL placement. What claim should the first practice submit?

Coding. Without removal of the hypermature lens, the only billable procedure is the vitrectomy: CPT code 67010–RT Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with mechanical vitrectomy. Use ICD-10 code H43.21 Crystalline deposits in vitreous body, right eye.

Dislocated IOL

Surgery. A patient has a dislocated IOL in his left eye. He needs either a scleral fixation or an exchange with an anterior chamber IOL, depending on intraoperative findings. What codes should be submitted?

Coding. If you need to reposition (with scleral fixation), use CPT code 66825 Reposition of intraocular lens prosthesis, requiring an incision (sepa­rate procedure). Here are your ICD-10 options: H27.122 Anterior dislocation of lens, left eye or H27.132 Posterior dislo­cation of lens, left eye and/or T85.22XA Displacement of IOL, initial encounter.

If you exchange the IOL, use CPT code 66986 Exchange of intraocular lens and ICD-10 code T85.21XA Breakdown (mechanical) of intraocular lens, initial encounter. If you are the original cata­ract surgeon and this occurs during the postop period, append modifier –78. You would not begin a new global period, and your payment will be reduced by the postoperative allowed amount.

Unexpected Refractive Error

Surgery. When a patient has an unex­pected refractive error after cataract surgery, can the practice code for an IOL exchange, or is the patient respon­sible for payment?

Coding. CPT code 66986 Ex­change of IOL would be appropriate and payable by insurance. The 2017 Coding Coach: The Complete Ophthal­mic Coding Reference’s listing for this code states, “For a variety of reasons, the physician may need to remove an existing IOL and replace it with a new one. Dislocation of the lens, incorrect power, or a problematic lens may be the reason.”

If the exchange is performed within the global period of the cataract surgery, append modifier –78, as this is an un­planned return to the operating room. Do not begin a new global period. The payment will be reduced by 20%.

Natural Lens in the Vitreous

Surgery. A patient, who had previously been diagnosed with cataracts, complained of sudden vision loss in his right eye. The exam revealed a spontaneous dislocation of his natural crystalline lens into the vitreous cavity. He underwent a pars plana vitrectomy, phacofragmentation of the dislocated natural crystalline lens from the vitreous cavity, and scleral fixation of a posterior chamber IOL. What codes should be submitted?

Coding. For the sutured IOL, submit CPT code 66982 for complex cataract surgery. Use ICD-10 codes H25.091 Other age-related incipient cataract, right eye and ICD-10 code H21.221 Degeneration of ciliary body, right eye.

As the vitrectomy was preplanned, submit CPT code 67036 Vitrectomy, mechanical pars plana approach and ICD-10 code H27.131 Posterior dislocation of lens, right eye.

Note: The 2 CPT codes are not bundled in Correct Cod­ing Initiative (CCI) edits.