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  • Complex cataract removal - what is the correct coding?

    First surgeon began cataract surgery that had to be aborted once the natural lens was removed, no IOL inserted. They placed a capsular tension ring and performed a partial vitrectomy. The patient was scheduled to return the following day for a second surgery by another surgeon.
    The following day, the second surgeon at the same practice removed the remnants of the natural lens along with capsular tension ring, repaired zonular dialysis using Ahmed capsular segments and performed an extensive pars plana vitrectomy prior to placing the new IOL. What is correct coding?

    No code exists for the description of the first surgery, but it qualifies as a complex cataract removal because a capsular tension ring was used. It is recommended you use CPT 66982 with the modifier -53 to indicate the surgery was discontinued. (Vitrectomy codes are bundled with cataract codes). As this will go to review, include a cover letter explaining at what point the procedure was discontinued and that IOL was not implanted. 

    For the second surgery, it is recommended to bill 66852 Removal of lens material; pars plana approach with or without vitrectomy and CPT 66985 Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal. Due to the use of modifier -53 on the first surgery, there is no need for a modifier since there is no global period, and the second surgery was done by a different surgeon.