How to code those complicated cataract surgeries

A billing primer for those rare glitches

By Paul M. Larson, MBA, COE, Senior Consultant, Corcoran Consulting Group

Cataract surgery is one of the most highly successful treatments in all medical history, with the cost-benefit equation to prove it. Further proof of my claim: Usually, all goes well.

But when the rare complicated surgery occurs, the proper coding for it may involve office visits, testing, and a major or minor surgical treatment; additionally, other providers are often involved, increasing the event’s coding complexity.

Another coding consideration: Some complications are intraoperative while others happen after discharge. If you want to obtain appropriate reimbursement, you will need to understand the relevant Medicare rules and regulations to ensure that you choose the correct codes. Most other payers follow Medicare rules, but they are not required to do so.

INTRAOPERATIVE CONSIDERATIONS

“Devices or techniques not normally used”

When complications are intraoperative and the surgeon handles them without assistance, code 66984 (standard extracapsular surgery with IOL implant) can often be changed to 66982, (complex extracapsular surgery with IOL implant). These sorts of complications usually fall under the code descriptor in CPT for 66982 that notes “devices or techniques not normally used.” Examples include the use of pupil expanders, capsular tension rings and suturing the IOL into position.

More than one surgeon

When two or more surgeons are needed on the same day, the main coding consideration is whether the surgeons belong to the same group or not. When they are part of the same group, because Medicare pays the group — not the individual surgeons (because physicians reassign benefits to the group) — the payer acts as though the surgeons are a single physician, and all surgeries performed in that surgical session are subject to the multiple procedure rules. The payments to the group for lower-valued billable surgeries are cut by 50%. Some payers want modifier 51 in addition to location (RT/LT) on the lower-valued code(s).

Although it’s not required, most group practices create some mechanism for adjusting the respective payments to individual surgeons within the group when the payer reduces the lower-valued surgery, because the end goal is proper patient care.

If any assisting surgeon is not part of the group, each provider is paid in full based on his/her own completed work as evidenced by the respective operative reports; no modifiers (other than RT/LT) are required. The co-surgeon modifier (62) is not implicated because the two surgeons are ophthalmologists (even if different subspecialtists).

POSTOPERATIVE COMPLICATIONS

Of groups and coverage

When another provider is brought in to deal with postoperative complications, the first consideration, when coding, is whether the second provider belongs to the same group as the first. The reason: The concept of global-surgery-packaging governs this scenario. When the providers are in the same group and a global surgical package is in effect, then Table 1A is appropros, as it lists what is covered, while Table 1B lists the excluded items. Table 2 lists the surgical modifiers that may be implicated inside the postoperative period for the initial surgeon’s group practice. Late complications (after the postoperative period has expired) do not require modifiers and are not affected by the global surgery package concept.

Note that when the two providers are not part of the same group (even if both are ophthalmologists), each provider bills without regard to the other. The tables might not apply unless the second surgeon implicates his own use of modifiers 25 or 57. This is because a global surgical package for the first surgeon doesn’t affect the second.

Below are examples showing what would be billable inside and outside a group-practice setting for different circumstances.

Example 1

Surgeon 1 notes that acuity is not at desired level due to post-op cystoid macular edema and sends the patient to retina. Retina treats the patient by getting an OCT and then performing a subconjunctival injection of triamcinolone.

If this is within the group, the OCT and triamcinolone are all that is billable by retina.

If the retina provider is outside the group and a new patient to retina, then it’s all billable (exam, test, injection and drug).

Example 2

Surgeon 1 notes at day-one post-op that a fragment of lens remains and sends the patient to retina. Retina examines the patient and decides to return to the operating room to do a parsplana vitrectomy to remove the fragment. If this is all done within the group, the retina surgeon’s exam is not billable, but the surgery (66852) in this case is billable (use modifier 58 because it is both related and of greater reimbursement value than the initial cataract surgery with IOL). The post-op period begins again for the group practice. Surgical payment is in full. Any tests would also be billable because they are not covered by the global surgical package (see Table 1B).

If the retina provider is not part of the cataract surgeon’s group, it’s all billable (exam, tests, and surgery). No modifiers are required for the exam or surgery unless done on the same day (See Table 1A for modifier 57’s use on the exam). As noted, tests aren’t part of a global package and, if the retinal surgeon needs to test the patient, he may. Each surgeon’s global package runs independent of the other even though each package involves the same eye.

Coding for complications can be complex; we hope this article can assist you. Knowing the subtleties of global package reimbursement and surgical modifiers is key to proper coding in these scenarios. OM

REFERENCES

About the Author
	Paul M. Larson, MBA, COE is a senior consultant with Corcoran Consulting Group. He is also COMT with extensive experience in clinical and educational ophthalmology and is a certified coder and medical chart auditor. He can be reached at plarson@corcoranccg.com or 800-399-6565, x 224.