Coding & Reimbursement

Mechanical Pupil Dilation During Cataract Surgery

By Suzanne L. Corcoran, COE

There are a number of circumstances in which cataract surgery may be considered complex and merit reporting as CPT 66982. Mechanical pupil dilation is one way to qualify for this code.

Q. What constitutes complex cataract surgery?

Complex cataract surgery is defined in CPT 66982 as: "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."

Q. What sort of "iris expansion" device might be used?

When patients do not respond to pharmacological agents, mechanical measures are necessary. Best known are the use of iris hooks (e.g., Lester Hooks, Katena, Denville, N.J.), a pupil dilator or iris retractors.

Additionally, some surgeons elect pupil expander rings (e.g., Morcher Pupil Dilator, FCI Ophthalmics, Marshfield Hills, Mass.). Iris expansion rings are gaining adherents among cataract surgeons because they provide stable mydriasis during cataract surgery with no trauma to the iris tissue. The capsulorrhexis, hydrodissection, phacoemulsification and injection of the IOL may occur with the device in place. At the conclusion of the procedure, the surgeon removes the pupil expander ring from the eye.

Q. What are the indications for use of mechanical pupil dilation?

Mechanical pupillary stretching is indicated in cases where topical or intracameral mydriatics are inadequate for proper dilation or are contraindicated. Most often these cases involve small pupils with rigid iris tissue due to prior use of miotics, pseudoexfoliation or posterior synechiae. In some cases of intraoperative floppy iris syndrome, with a constricted pupil, mechanical pupil dilation is necessary.

Q. What diagnosis codes are appropriate for complex cataract surgery?

Some acceptable codes are 364.71 (posterior synechiae), 366.11 (pseudoexfoliation), 364.23 (lens-induced iridocyclitis), 366.20 (traumatic cataract), 379.32 (subluxation of the lens) and 364.81 (floppy iris syndrome). Check with your local Medicare carrier for a list of suitable ICD-9 codes.

Q. What is the Medicare reimbursement for 66982?

In 2007, the national Medicare Physician Fee Schedule amount is $898.93 (at press time, the fee was not finalized for 2008). This amount is adjusted by local wage indices. Reimbursement is about 40% higher than the Medicare rate for regular cataract surgery with IOL (66984).

Q. What about facility reimbursement?

In 2001, CMS published a Program Memorandum announcing that Medicare will pay an ambulatory surgery center (ASC) facility fee for 66982 in payment group 8. The national allowed amount effective April 1, 2004, is $973; this amount is adjusted by local wage indices.

CPT 66982 also receives facility payment in a hospital outpatient department (HOPD). As in the ASC, facility payment is equivalent to that for 66984. In 2007, the national Medicare allowed amount is $1,452.57, adjusted by local wage indices.

Q. Is there additional reimbursement for the iris expansion device itself?

No. The device is included in the reimbursement for the facility fee and the hospital or ASC is precluded from balance billing the beneficiary for it. So even though the surgeon receives additional reimbursement for complex cataract surgery, the ASC and HOPD do not.

Q. How frequently is 66982 used?

Not often. Of all Medicare claims paid during 2005, complex cataract surgery accounts for just 5% of all cataract extractions with IOL. However, ophthalmic practices vary and some surgeons may perform this procedure more frequently by virtue of the extraordinary populations they serve. Other surgeons may elect to avoid these difficult cases altogether and never report 66982. OM