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  • Planning for Complex Cataract Surgery

    Question: A patient has phacodonesis and is scheduled for complex cataract surgery. There is no mention of sutures, Malyugin ring or hyper mature cataract in the exam notes. In documenting the surgical order, is it better to plan for complex and down code or plan for standard and up code with addendum if the case warrants 66982?

    Answer: It is best to plan for the cataract surgery as ordered but review the op report to see if documentation of devices or techniques not generally used in routine cataract surgery supports complex cataract surgery, CPT 66982. Complex cataract surgery does not need to be preplanned; it just must meet the definition.

    Always consider who the payer is and their unique requirements. If prior authorization is required, request it for both 66984 and 66982.
    Additional information on complex cataract surgery can be found in Cataract Surgeries Can Be Complex, Coding Doesn’t Have to Be.