Coding and Reimbursement
Coding Complex Cataract Surgery
An expert clarifies when, and how, to get reimbursed for more than "standard" surgery.

BY SUZANNE L. CORCORAN, COE

In 2001, a new code was added to CPT for complex cataract surgery (66982). The code was modified in 2002; it now reads, "Extracapsular cataract 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 capsulorhexis) or performed on patients in the amblyogenic developmental stage."

Surgical situations that might qualify as complex cataract surgery include:

• surgery on a patient with pupils that don't dilate because of chronic parasympathomimetic drug use, scarring or trauma (In such cases, mechanical dilation of the pupil during surgery is necessary to extract the cataract and implant an IOL.)
• cases in which the surgeon is required to suture the haptics of the IOL
• some pediatric surgeries
• patients with a subluxated lens.

Other procedures requiring additional instrumentation or added steps, such as ICG prior to capsulorhexis, may also qualify as complex cataract surgery.

Some acceptable diagnosis codes are:

• 364.23 (lens-induced iridocyclitis)
• 366.20 (traumatic cataract)
• 379.32 (subluxation of the lens).

Note: The third code listed above is acceptable as long as the operative note indicates the IOL was supported by using permanent intraocular sutures or a capsular support ring.

Q: What kinds of cases don't qualify as complex? Cases that require more time than usual aren't always complex. A case may take longer simply because the lens requires more phaco time, or because of an unplanned anterior vitrectomy to manage surgical misadventures. In the latter situation, the vitrectomy is bundled with cataract surgery under Medicare's NCCI edits; the surgery shouldn't be considered complex.

Q: What about bundling? The same NCCI bundles apply to complex cataract surgery as to regular extracapsular cataract surgery with IOL implantation (66984).

Q: Are there any special documentation requirements? Operative reports for complex cataract surgery are characteristically longer and more descriptive than those accompanying ordinary cataract surgery with implantation of an IOL. The operative report should include a description of the preoperative indications that made the case complex, as well as the additional steps that were taken to address the unique difficulties of the procedure.

Q: What about payment rates? The national Medicare payment rate for the surgeon for 66982 in 2002 is $845.98, which is about 26% higher than the Medicare rate for regular cataract surgery with IOL (66984). Also, on May 15, 2001, CMS published a program memorandum announcing that Medicare will pay an ASC facility fee for 66982 in payment group 8. The national reimbursement for the ASC in 2002 is $949.

As always, national payment rates are adjusted by local wage indices.

Q: How often will Medicare pay for this service? Generally, complex cases account for less than 2% of all cataract procedures. Of course, some practices, particularly those that specialize in difficult cases, may use this code more than 2% of the time.

In any case, we believe that Medicare carriers and other payers will pay close attention to these claims, and may request operative notes to justify reimbursement.

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800)399-6565 or via email at scorcoran@corcoranccg.com.