coding & reimbursement
Coding Complex Cataract Surgery
Not all difficult surgeries qualify as "complex."

In 2001, the Health Care Financing Administration added CPT code 66982 to describe complex cataract surgery. Today, the code description (modified in 2002) 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 capsulorrhexis) or performed on patients in the amblyogenic developmental stage."

Here are answers to common questions about using this code.

Q: What qualifies a procedure for coding as complex cataract surgery? Cataract surgery may be considered to be complex for many reasons, including:

• it's necessary to mechanically dilate the pupil because of chronic parasympathomimetic drug use, scarring, or trauma
• it's necessary to suture the haptics of the IOL
• the lens is subluxated
• a dye (e.g., ICG) must be used prior to capsulorrhexis because the cataract is very dense
• it's necessary to use capsular tension support.

Q: Does stretching a small pupil qualify as complex cataract surgery? Yes. An extra step such as mechanical dilation with surgical instruments or a pupil stretcher (because pharmaceuticals don't dilate the pupil sufficiently to permit removal of the cataractous lens) is not normally required.

Q: Can I use a capsular tension ring? Yes. Morcher's capsular tension ring (CTR) was approved by the FDA in October 2003, and is indicated for patients with weak or partially absent zonules, including primary zonular weakness (e.g., Marfan's Syndrome), secondary zonular weakness (e.g., trauma), and cases of zonulysis, pseudoexfoliation, and Marchesani's Syndrome. Code 66982 is appropriate to report cataract surgery involving a CTR.

Q: Are there any special documentation requirements for complex cataract surgery? The operative report should include a description of the preoperative indications that made the case complex, as well as the additional steps 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 2004 is $899. Reimbursement is about 31% higher than the Medicare rate for regular cataract surgery with IOL (66984).

Complex cataract surgery (again coded 66982) is also included on the list of ASC-covered procedures in payment group 8, along with regular cataract surgery. The national reimbursement for ASC-covered complex cataract surgery, as of April 1, 2004, is $949. (As always, national payment rates are adjusted by local wage indices.)

Q: How often will Medicare pay for this service? It's estimated that complex cases account for less than 2% of all cataract procedures. However, in some practices -- particularly those to which difficult cases are often referred -- utilization of this code may be higher than 2% because of the practice's unique circumstances. We believe Medicare carriers and other payers will pay close attention to these claims, and may request operative notes to justify reimbursement.

Q: What situations don't warrant coding as complex? Cases that require more time than usual (for example, more phaco time) don't always qualify as complex surgery. Also, some cases require unplanned anterior vitrectomy because of surgical misadventures. When this happens, the vitrectomy should be bundled with cataract surgery under Medicare's NCCI edits; it shouldn't be considered complex. (Note: The same NCCI bundles apply to complex cataract surgery as regular extracapsular cataract surgery with IOL [66984]).

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.