Following the release of the Centers for Medicare & Medicaid Services’ (CMS) comparative billing report (CBR) in September 2022, the Academy received questions about how to correctly code and bill for the services listed in the report. The second metric compared the percentage of YAG procedures (CPT code 66821) performed within 18 months of cataract surgery in the same eye. In a follow up webinar, CBR PEPPER, the CMS contractor for CBR reports, clarified a secondary cataract surgery on the same eye performed by the same or different provider within 547 days is counted in the numerator for the second metric. Although it remains unclear why CMS chose a period of 18 months, it is important that CMS has identified the code set as vulnerable to improper payments.

Whether your practice received a CBR letter or not, review your current YAG capsulotomy documentation and billing. Use the checklist below to ensure appropriate documentation and coding for YAG laser capsulotomy. 

• Patient names and identifiers are present on all pages of the medical record.
• Chief complaint of visual loss or symptoms of glare are unique to each patient (no cloning between patients).
• Best corrected visual acuity (BCVA) has been recorded.*
• The activities of daily living statement notes that the patient is unable to function adequately with the current level of vision.
• An exam has documented the amount of posterior capsular opacification or other probable causes of decreased vision following cataract surgery.
• The physician has provided a statement that capsular opacification is believed to contribute to visual impairment when more than one ocular disease is present.
• The physician has provided a statement that there is reasonable expectation that laser treatment will improve vision.
• The patient desires and agrees to proceed with laser treatment.
• The risks, benefits and alternatives were explained, and you have obtained the patient’s signed consent.
• A physician's order for the procedure has been documented.
• The procedure notes include laterality, procedure type (YAG laser capsulotomy), diagnosis and procedure description.
• A valid and legible physician signature is present.

Not every Medicare Administrative Contractor (MAC) has a Local Coverage Determination or article policy for YAG laser capsulotomy. Be sure to check your local MAC policies at aao.org/lcds, along with commercial or Medicaid payer policies.

*At time of publication, Medicare administrative contractors (MACs) Cigna Government Services (CGS) and Palmetto have published BCVA criteria. Palmetto restricts coverage within three months following cataract surgery unless specific medical necessity criteria are met and documented.


Additional Resources

Local coverage determination aao.org/lcds

2023 Coding Assistant: Cataract and Anterior Segment (aao.org)

Schedule Coding and Practice Management Consultations for Ophthalmology (aao.org)

Ask the experts:

Appending modifier on bundled services - American Academy of Ophthalmology (aao.org)

Submit claim for bilateral capsulotomy on Medicare Part B patient - American Academy of Ophthalmology (aao.org)

How to bill incomplete YAG capsulotomy (aao.org) 

Billing Patients for Repeat Surgeries in Global Period - American Academy of Ophthalmology (aao.org)