Unplanned anterior vitrectomy and its relationship to cataract surgery

One of the final quality reporting measures for ASCs in 2017 assesses the percentage of unplanned anterior vitrectomies performed in conjunction with cataract surgery in an ASC. Information collected in 2018 will be used to determine payment rates for 2020.

Unplanned anterior vitrectomy occurring in conjunction with a cataract procedure is usually considered an untoward event with negative implications regarding a surgeon’s skills. This is a misconception, because often there are underlying pathological/physiological reasons for the occurrence. Furthermore, CMS (Center for Medicare and Medicaid Services) acknowledges that proportionately, this is not an exceedingly high-volume occurrence.

Here, I discuss the assignment of a vitrectomy to the unplanned category and its associated type of cataract surgery, focusing on occurrences with complex cataract extraction as well as potential difficulties in abstracting the information.

ASC 14: Unplanned Anterior Vitrectomy

The Final Rule regarding ASCs was published in the Federal Register, dated November 14, 2016.¹ Further critical information is provided in the ASC Quality Measures: Implementation Guide.² The following highlights are of importance:

• Definition. An unplanned vitrectomy is performed when vitreous inadvertently prolapses into the anterior segment of the eye during cataract surgery, and the vitrectomy was not scheduled at the time of admission to the ASC.
• For purposes of this measure, only the following CPT cataract surgery codes should be used:
• 66982: Cataract surgery with insertion of intraocular lens, complex
• 66983: Cataract surgery, intracapsular, with insertion of intraocular lens
• 66984: Cataract surgery, extracapsular, with insertion of intraocular lens
• Rationalization for the Measure. CMS’s rationale is that the improvement of patient care over time can be achieved by making the rate of this complication available to patients and ASCs, thus incentivizing ASCs to incorporate quality improvement steps to reduce its incidence. CMS also believes that because the reporting of the performance data will be public, this also will enhance the aforementioned incentivization.
• Measure Calculation. A percentage is calculated by dividing the total number of cataract surgeries in which an unplanned vitrectomy was performed (the numerator) by the total number of cataract surgeries performed (the denominator).
• Data Collection. The data will be collected by the ASC using chart abstraction and sent to CMS via a CMS online data submission tool, (QualityNet; qualitynet.org ).
• Time Frame. “… the data collection period for the proposed ASC 14 measure would be the calendar year 2 years prior to the applicable payment determination year. For example, for calendar year 2020 payment determination, the data collection period would be calendar year 2018. We also proposed that ASCs submit the data to CMS during the time period January 1 to May 15 in the year prior to the affected payment determination year. For example, for the calendar year 2020 payment determination, the submission period would be January 1, 2019 to May 15, 2019…”¹ Thus, for the data collection period of January 1, 2018 to December 31, 2018, that data would be submitted from January 1 to May 15 in 2019.

Coding & Compliance Considerations

CPT Codes for Anterior Vitrectomy.

The referenced documents do not specify which vitrectomy codes should be used; however, I opine the intent is 67010. For purposes of this measure, only mechanical vitrectomy should be counted. It is important to note that the full description of an indented code always includes up to the semicolon of the non-indented code before it. There are two CPT codes for anterior vitrectomy:

• 67005: Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal
• 67010: Subtotal removal with mechanical vitrectomy

A parenthetical note states: “For removal of vitreous by paracentesis of anterior chamber, use 65810.” However, this use falls outside of the parameters of this measure.

CPT code 67005 describes manual techniques for removal of vitreous, such as when using a surgical sponge and scissors compared with CPT code 67010 that describes using a mechanical device for removal of the vitreous.

Do not include retina/vitreous posterior vitrectomy codes (CPT code 67036, etc.) as one of the codes to use in reporting. However, note that the anterior vitrectomy may be performed by either an anterior or pars plana approach.

Planned Vitrectomy and Exclusions

If a patient is scheduled to have a cataract extraction with insertion of an intraocular lens and a planned or potential vitrectomy, the case should not be included in the numerator statistics for the measure.

There are times when the possibility of performing a mechanical anterior vitrectomy may be anticipated by the surgeon. Examples of the type of cases that might be involved include removal of subluxated lenses and the performance of a primary posterior capsulorrhexis. Be sure to exclude cases in which the surgeon notes in advance in the chart notes, or it is apparent from the diagnosis, that an anterior vitrectomy may be performed. Trauma cases that include traumatic cataract are also excluded from the measure.

One of the questions that will occur is whether or not to include discontinued procedures. The CPT modifiers differ for discontinued procedures for ASC coding versus physician coding. For ASCs, the modifier 73 or 74 is selected based on whether the procedure is discontinued before or after anesthesia, compared with the physician definition that is based on whether or not the procedure has commenced.

For ASC coding, when the procedure is discontinued before anesthesia is given, that case should not be part of the measure (modifier 73). However, for the majority of cases, keeping in mind the exclusions previously noted — if the procedure is discontinued after anesthesia is given, surgery has commenced and the need for an unplanned anterior vitrectomy occurs, and if there were no prior indications that an anterior vitrectomy might be performed — then the case should be included.

Complex Cataract Extraction CPT Definition: 66982

”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 (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage.”

The CPT definition of complex cataract should be reviewed carefully, taking note that the word “complication” does not appear in the definition. The concept that a complication, such as vitreous loss necessitating an anterior vitrectomy, qualifies the case as being considered complex is erroneous and has led to miscoding and possible future Medicare audits as witnessed by those physicians receiving Comparative Billing Reports citing their excessive use of the complex cataract extraction code.³ It also is a focus of Supplemental Medicare Review Contractor audits that are similar to Recovery Audits (or RAC).⁴

According to the American Medical Association’s publication entitled CPT Changes 2001: An Insider’s View, the following original rationale is given for this new code:⁵

“[Code] 66982 has been added to delineate procedural differences associated with the removal of extracapsular cataract(s) and lens insertion performed in the pediatric age group, on patients who present with diseased states, prior intraocular surgery, or with dense, hard and/or white cataracts. The presence of trauma, or weak or abnormal lens support structures caused by numerous conditions (e.g., uveitis) and disease states (e.g., glaucoma, pseudoexfoliation syndrome, Marfan syndrome) require additional surgical involvement, and utilization of additional techniques and surgical devices. A small pupil found in a patient with glaucoma or a past surgical history may not dilate fully, and will require iris retractors through additional incisions. Capsular support rings to allow the placement of an intraocular lens may be required in the presence of weak or absent support structures.

Pediatric anatomy contributes to the complexity of cataract surgery. The anterior capsule tears with great difficulty and the cortex is difficult to remove from the eye because of intrinsic adhesion of the lens material. Additionally, a primary posterior capsulotomy or capsulorrhexis is necessary, which further complicates the insertion of the intraocular lens.”

Over time, additional interpretations and guidelines were developed by the Medicare Administrative Contractors (MACs) and set forth in their Local Coverage Determinations. Not all MACs have or had these guidelines for complex cataract extraction. Updated information can be found at RivaLeeAsbell.com .⁵

In most cases, the use of code 66982 can be anticipated preoperatively. Sometimes a planned anterior vitrectomy can be anticipated. It is best to have this documented in the chart notes preoperatively so that when the case is scheduled it will not be counted as an unplanned vitrectomy.

Financial and Audit Considerations

Consider a training meeting with the surgeons to discuss coding. It is best that both the surgeon and the ASC submit the same CPT codes, although this does not always occur.

The anterior vitrectomy codes are bundled with the cataract extraction codes under the National Correct Coding Initiative and the bundle should not be broken. This applies to physician coding as well. Use of modifier 59 to break these bundles is a red flag for a Medicare audit. Noting the performance of a quality measure in your log does not equate to using the same codes for coding/billing purposes.

Clinical Considerations and Clarifications

The profile of included cases should be only those scheduled for cataract extraction with insertion of an intraocular lens when the complication of vitreous loss necessitating an unplanned anterior vitrectomy occurs. If another procedure — such as a corneal transplant, glaucoma stent insertion, or traumatic open globe with vitreous loss — is performed, then none of those cases would qualify for inclusion in the Measure.

Exclusions

Do not include these types of cases:

• Surgeries with a planned anterior vitrectomy or anticipated anterior vitrectomy.
• Surgeries discontinued after surgery has commenced due to various complications other than unplanned vitrectomy that necessitate cancelling the rest of the procedure.
• Surgeries with techniques that do not include the cataract extraction such as secondary IOL insertion.
• Surgeries with complications, such as dropping of the nucleus into the posterior segment, that are discontinued and referred to other surgeons (i.e., retinal surgeons).
• Surgeries that include performing an additional procedure that is not related to the cataract with IOL insertion procedure, such as a cataract insertion with IOL + corneal transplant + anterior vitrectomy or cataract insertion with IOL + insertion of iStent.

Practice Makes Perfect

ASC personnel may think they will wait until the end of 2017 to set up the administrative procedures. I recommend an earlier start and some practice before it counts. Some of the parameters of this measure may not be as apparent as one would wish and may need further clarification, as well as further refinement for specificity, in order for ASCs to set up their criteria and systems for data collection, abstraction and transmission. ■

CPT Codes copyright 2017 by the American Medical Association.

References

1. Federal Register/Vol.81, No. 219/Monday, November 14, 2016/Rules and Regulations, p.79801-79803;
2. ASC Quality Measures: Implementation Guide. Version 4.0. September 2016. http://www.ascquality.org/qualitymeasures.cfm ;
3. Comparative Billing Report information may be found at http://www.cbrinfo.net ;
4. CPT TM Changes 2001: An Insider’s View. American Medical Association. 2001;
5. Asbell, R.L.: Coding for Complex Cataract Surgeries (2015 updates). http://rivaleeasbell.com/articles2.php?category=Cataracts