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  • Cataract Surgeries Can Be Complex, Coding Doesn’t Have to Be

    As a result of the comparative billing report released by the Centers for Medicare & Medicaid Services (CMS) last month, the American Academy of Ophthalmic Executives® has received many questions about how to correctly code and bill for the services listed. 

    The first metric compared the percentage of cataract surgeries billed as a complex procedure (CPT 66982). Whether your practice received this most recent report or not, now is the time to review your current complex cataract billing practices. Below is a review of the best practices for documentation, coding, and billing for complex cataract surgeries. 

    The definition of CPT code 66982 uses the same wording found in standard cataract surgery (CPT 66984): “Extracapsular cataract extraction removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex,” and then adds this important distinctive statement “requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage.” This additional statement is the key to determining if cataract surgery qualifies as complex. The operative report should clearly indicate the how and the why of cataract surgery:

    • Why: The indications (supporting diagnosis) for their use  
    • How: The devices or techniques used

    Not every Medicare administrative contractor has a local coverage determination policy for complex cataract surgery, but those that do all provide similar indications. Review these four questions to determine if your case is complex or not:

    • Is it a miotic pupil that will not dilate sufficiently thus requiring the use of special instruments?
    • Does the IOL need additional support, such as a capsular tension ring or intraocular sutures?
    • Is this a pediatrics case that includes the implantation of the IOL?
    • Is the cataract considered mature, requiring the use of dye?
    Check with the payer since not all consider the use of dye a covered reason for complex cataract surgery.

    If the answer is yes to any of these questions, then submit CPT code 66982. Remember that the determining factor of if the cataract surgery qualifies to be coded as complex is not based on the difficulty of the case but rather on the use of additional devices or if you are operating on a child.
    Most complex cases are known before surgery, however, if intraoperatively additional qualifying devices and techniques are necessary, used, and documented, be sure that both the physician and facility submits the case as “complex,” CPT 66982. 

    Further Resources

    Find your local coverage determinations for complex cataract surgery at Local Coverage Determination Policy overview.

    Common ophthalmology-related coding and billing questions can be found at Coding News and Expert Advice.

    Checklists and fact sheets to help you accurately code for surgical procedures of the anterior chamber 2023 Coding Assistant: Cataract and Anterior Segment

    Receive customized support for all your coding and billing needs by registering for Academy private consultation services.