Last spring, approximately 10,000 ophthalmologists received a comparative report focusing on cataract surgery billing (CPT codes 66984 and 66982). Those who received such a letter were found to submit more of these cases than their peers. Since that time, the American Academy of Ophthalmic Executives has received many questions about how to correctly document and bill for complex cataract surgery. Here are some tips to help you code with confidence — even in the most complex of situations.
Identifying the Complex Case
More and more ophthalmologists fear billing CPT code 66982, which is defined as:
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, 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
As a result, many ophthalmologists opt to not submit it. But is it indeed risky to bill complex cataract surgery given the letter sent last year?
No. The report was data driven only. No actual charts were audited; however, based on the findings, payers may choose to perform an audit. Therefore, to bill for a case that is determined to be complex, you need to support it with proper documentation. Although not every Medicare Administrative Contractor has a Local Coverage Determination policy for complex cataract surgery, those that do all provide similar indications.
Answer 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?
If the answer is “yes” to any of these questions, then submit CPT code 66982. Keep in mind that this code selection is not based on the difficulty of the case but rather on the use of additional devices or if you are operating on children.
Documenting the Complex Case
The operative report should clearly indicate what has made this unique case complex. You may also submit a secondary diagnosis providing the reason that you needed special instruments or devices. For a listing of potential secondary diagnoses and when to use them, see Ask The Coding Experts for ICD-10.
Most often, you’ll know prior to surgery whether or not the case will be complex; however, if you determine intraoperatively, be sure the facility updates its claim and submits the case as “complex” as well. Both you and the facility should submit the same CPT code to the payor.
In the end, don’t be afraid to submit for what you’ve performed. Just make sure your documentation supports the service being billed.
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About the author: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series.