Coding & Reimbursement

Complex cataract surgery: getting a closer look

Know what qualifies as “complex” and what does not.

By Suzanne L. Corcoran

The shift to ICD-10 has brought many coding-related issues into sharper focus and caused practices to take a second look at their assumptions. A prime example of this is coding for complex cataract surgery. On the Listservs and cyber chats we have noticed a lot of discussion among practices, and heard from our own clients, about complex cataract surgery and whether the condition that makes it complex needs to be coded along with the diagnosis of cataract. The consensus, and we agree, is that it should, when possible. We hope the following provides some clarity for you.

Q. What is complex cataract surgery?

A. CPT defines complex cataract surgery (66982) as follows: “Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorhexis) or performed on patients in the amblyogenic developmental stage.”

Q. Are there coverage and payment policies that describe when we can bill 66982?

A. Yes. Not all Medicare Administrative Contractors have published Local Coverage Determinations (LCDs), but those who do are fairly consistent. Covered indications include, but are not limited to, the following:

• Use of a capsular tension ring for conditions such as floppy iris syndrome (H21.81) iridodialysis (H21.53-), or other specified or unspecified disorders of iris and ciliary body (H21.89, H21.9, H22). Zonular weakness, as occurs with pseudoexfoliation (H26.8 or H40.14-), may require use of a capsular tension ring.

• Use of Trypan Blue (Thermo Fisher Scientific), indocyanine green or other dye to stain the capsule to aid in visualization when the cataract is very dense (H25.-).

• Use of iris hooks^* or Beehler pupil dilator (or similar device) for conditions such as miotic pupil (H57.03) or tonic pupil(H57.05-), iris atrophy (H21.279), diabetic cataract (E10.36, E11.36, E13.36, etc.), neovascularization (H26.21-), or cataracts secondary to degenerative or inflammatory ocular disorders (H26.22-).

• Suturing the IOL in place because of degeneration of ciliary body (H21.22-), dislocated lens (H27.1-), or when needed for traumatic cataract (H26.11-, H26.13-).

• Placing a prosthetic iris during cataract surgery for aniridia (Q13.1).

The operative report must include a description of what the surgeon did as well as the medical condition requiring the additional work in complex cataract surgery. Noting the presence of floppy iris syndrome is fairly straightforward, but documenting the density of the cataract that necessitates using capsular dye is often forgotten. Remember that the operative report should stand alone as documentation; a reviewer may not have access to the full medical record.

Q. When is 66982 not supported?

A. More surgical time does not, in itself, constitute complex. For example, a case may be longer if the posterior lens capsule breaks or the lens is very hard — but it’s not complex. Within Medicare’s NCCI edits, anterior vitrectomy is part of routine cataract surgery and does not support billing 66982.

Neither does using advanced technology IOLs, such as presbyopia-correcting or astigmatism-correcting lenses, qualify as complex surgery. The same is true for femtosecond laser-assisted cataract surgery. While many subtle variations exist in cataract surgical technique (eg, incision location, marking the eye), they typically fall within the confines of conventional cataract surgery. A procedure can only be coded 66982 if CMS considers it complex.

Q. What is the frequency of complex cataract surgery?

A. Medicare Part B data from 2014 indicate that complex cataract surgery comprises about 8%-9% of all cataract procedures with implantation of an IOL. Data are not available for Medicare Part C (Medicare Advantage), but we expect the frequency is similar. Non-Medicare data are not publicly available.

The frequency of complex cataract surgery varies among surgeons, and with good reason. Surgeons who serve particular ethnic groups with high prevalence of pseudoexfoliation tend to use capsular tension rings more frequently. Some physicians serve an abnormal patient population due to referral patterns. Some surgeons avoid cases that might be complex, such as patients who take Flomax (tamsulosin HCl, Boehringer Ingelheim Pharmaceuticals).

Above-average use of this code may prompt unwanted attention from Medicare and other payers, so thorough documentation is essential. OM

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