Coding & Reimbursement

Complex cataract surgery: A code all its own

By Suzanne L. Corcoran

Q. What is complex cataract surgery (66982)?

A. CPT code 66982 is described 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.”

A complex cataract surgery may be performed on a patient with pupils that do not dilate because of chronic parasympathomimetic drug use, scarring or trauma. In such cases, mechanical dilation of the pupil is necessary to enable the surgeon to extract the cataract and place an IOL.

Another example of complex cataract surgery: when the surgeon is required to suture the haptics of an IOL or implant a capsular tension ring. Pediatric cataract surgery with an IOL almost always involves primary posterior capsulorrhexis, which is defined as complex cataract surgery in the CPT description.

Q. Does the use of dye to assist visualization of a dense cataract qualify?

A. Maybe not. The March 2016 issue of the CPT Assistant says that “the additional work of instilling and removing Trypan Blue dye from the anterior segment though an additional surgical step does not reach the threshold of physician time, work, or intensity necessary to report the complex cataract code.”

If specifically stated in the local policy, a payer may allow the nonroutine use of dye in dense, mature or hypermature cataracts as complex surgery. At this time, only four Medicare Administrative Contractors (MACs) allow this: Novitas Solutions,¹ Palmetto GBA,² CGS Administrators³ and National Government Services (NGS).⁴ Without specific instructions to the contrary, the CPT Assistant guidance should be followed. With the March CPT Assistant publication, we believe more payers will decide not to count the use of dye as supporting 66982. Watch your payer bulletins.

Q. What other types of cataract surgery would not be considered complex?

A. Cases that require more time than usual are not necessarily complex. For example, a case may be longer if the lens requires more phaco time. Also, some cases require unplanned anterior vitrectomy for surgical misadventures. The vitrectomy is bundled with cataract surgery under Medicare’s NCCI edits and does not, by itself, render the case complex.

In addition, the implantation of an accommodative or multifocal IOL, instead of a standard monofocal IOL, does not necessarily require any special devices or unusual techniques and does not qualify as complex surgery per se. The same is true for a toric IOL. The use of a femtosecond laser for cataract surgery does not qualify as complex. While many subtle variations exist in cataract surgical technique (e.g., incision location, marking the eye), they usually fall within conventional cataract surgery.

It’s important to remember that CPT 66982 is judged on a case-by-case basis and Medicare could require an operative report to support the claim.

Q. Must complex cataract surgery be preplanned?

A. No. Some intraoperative surprises may require techniques that are best described as complex cataract surgery.

Q. Which diagnostic codes support complex cataract surgery?

A. Some ICD codes may include:

Check with your local MAC for a complete list. Some payers require two or more ICD codes.

Q. How frequently is 66982 used?

A. Of all Medicare claims paid during 2014, complex cataract surgery comprised 9% of all cataract extractions with implantation of an IOL. Surgeon utilization rates vary; some are more inclined to perform complex cataract surgery than others.

Q. What does Medicare allow for 66982?

A. Surgeon reimbursement is about 25% higher than the Medicare rate for conventional cataract surgery with IOL (CPT 66984). In 2016, the national Medicare Physician Fee Schedule-allowed amount for 66982 is $806. This amount is adjusted by local wage indices. Other payers set their own rates, which could differ significantly from the Medicare published fee.

Q. How about the facility fee?

A. The 2016 HOPD facility payment for 66982 is $1,746, and the ASC payment is $976. These are the same facility payment rates as for conventional cataract surgery with IOL; while there is a differential for the surgeon, there is none for the facility. OM

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