CODING & REIMBURSEMENT

Your guide to correct YAG coding

By Suzanne Corcoran

Questions about Medicare rules for YAG laser capsulotomy (CPT 66821) still come up. Here are some that practices ask about the most.

Q What are the indications for YAG laser capsulotomy?

A Most Medicare coverage policies are similar and require the following, but check with your local contractor. Indications are:

• An impaired ability to carry out activities of daily living due to decreased vision.

• Best-correct visual acuity of 20/30 or worse or a decrease of 2 lines of visual acuity.

• Other eye diseases have been excluded as the primary cause of visual disability.

The patient’s medical record must document that coverage criteria have been met. Appropriate 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

Q What documentation is required 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. We also recommend a lifestyle questionnaire to document the patient’s specific complaints. Payers expect a consent form and operative note, even when the laser is performed in the office.

Q What about repeat YAG procedures?

A Occasionally, the capsular opening is not large enough, or constricts slightly during the post-operative period, and the surgeon will perform a second procedure to remedy this. Medicare considers this a continuation of the initial treatment; there is no separate payment, but repeat lasers are covered as part of the global surgery fee for the original procedure.

Q Will Medicare cover YAG capsulotomy performed in the global surgery period following cataract surgery?

A Sometimes. Most Medicare contractors allow payment for this procedure if the patient meets the visual criteria, but expect this to happen rarely. The location where the YAG is performed also 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; submit claims with modifier 78. Note that a dedicated laser suite in the surgeon’s office is considered an operating room in this context.

Recently, the number of early YAG capsulotomy in patients who receive presbyopia-correcting IOLs (P-C IOL) has increased. Oftentimes, the patient is symptomatic yet does not meet the visual requirements for YAG outlined in Medicare’s policies. Medicare does not cover these laser surgeries; however, the surgeon may be compensated for them as part of the “upgrade” package for implanting a P-C 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.