Coding & Reimbursement

Continuing Questions About YAG

By Suzanne L. Corcoran, COE

YAG laser capsulotomy is a common procedure, but questions still arise about its Medicare rules.

Q. What are the indications for YAG laser capsulotomy?

A. Ophthalmologists are quite familiar with the process of using a YAG laser to cut through an opacified posterior lens capsule and/or adjacent hyaloid membrane to restore clear vision in postop cataract patients.

Most Medicare coverage policies are very similar and require the following:

• An impaired ability to carry out activities of daily living due to decreased vision.
• Decreased BCVA of 20/30 or worse or a decrease of two lines of visual acuity.
• Other eye diseases have been excluded as the primary cause of visual disability.

Check your local coverage policies for more details and specific guidance.

Q. What diagnoses support a claim?

A. Appropriate ICD-9 diagnosis codes may vary from one Medicare policy to another, but most policies include the following:

• 366.50 After-cataract, unspecified
• 366.51 Soemmering's ring
• 366.53 After-cataract, obscuring vision
• 996.53 Mechanical complication of ocular lens prosthesis

Note that the use of these codes does not guarantee reimbursement. The patient's medical record must document that coverage criteria have been met.

Q. How should this procedure be documented in the medical record?

A. The indications for YAG laser capsulotomy should be clearly identified in the notes for the exam prior to the surgery. Regardless of the place of service (office, ASC or hospital), a consent form and operative note are expected.

The key components of an operative report are: operated eye, indications, pre-op instructions and medications, type of laser (only FDA-approved lasers are appropriate), laser setting (wavelength, power setting), treatment details (size and number of applications, duration of laser, placement of spots) and discharge instructions.

Q. Are repeat YAG procedures during the global surgery period covered?

A. There is no separate payment, but repeat lasers are covered as part of the global surgery fee for the original procedure. Occasionally, the capsular opening is not large enough, or constricts slightly during the postoperative period, and the surgeon will perform a second procedure to remedy this. This is considered a continuation of the initial, failed, treatment.

Q. Is reimbursement made for YAG capsulotomy performed in the global surgery period following cataract surgery?

A. Sometimes. Most Medicare contractors allow payment for this procedure if the visual criteria are met, but expect it to happen rarely. The location where the YAG is performed affects the answer. Related surgical procedures performed in the office during the global period are considered part of the postoperative care and are not separately billable.

Procedures requiring a return to the operating room are reimbursed in the postoperative period; claims are submitted with modifier 78. Note that a dedicated laser suite in the surgeon's office is considered an operating room in this context (MCPM, Ch 12, §40.1B).

Recently, there has been an increase in early YAG capsulotomy in patients who receive presbyopiacorrecting IOLs (PC IOL). Oftentimes, the patient is symptomatic yet does not meet the visual requirements for YAG outlined in Medicare's policies. These laser surgeries are not covered; however, the surgeon may be compensated for them as part of the “upgrade” package for implanting a PC IOL.

Q. Is 66821 appropriate for YAG laser of the anterior capsule or to remove specks from the surface of the IOL?

A. No. CPT 66821 is specifically defined as treatment on the “opacified posterior lens capsule.” There is no specific code to identify procedures on the anterior capsule or IOL. Use CPT 66999 (unlisted procedure, anterior segment) to describe these services. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.