The Center for Medicare and Medicaid Services (CMS) has increased efforts to contain compliance infringements regarding coding and billing of Current Procedural Terminology (CPT) code 66982—the complex cataract code. For years now, external auditors have been engaged by CMS to audit complex cataract surgery claims. These audits are commonly known as Supplemental Medical Review Contractor (SMRC) audits.

The basis for this overutilization is a basic misunderstanding of the differences between “complex” and “complications.” This article reviews the definition, requirements, and chart documentation necessary to code a case as complex.

The original definition, one that finally emerged after considerable wordsmithing, was presented to and accepted by the CPT Editorial Panel in 2000, and I was part of the original team. While the code first appeared in CPT 2000, further clarifications and subsequent regulations were, and continue to be, issued as Local Coverage Determinations (LCD) by the Medicare Administrative Contractors (MACs).

DEFINITION & DIFFERENCE DELINEATIONS BETWEEN CPT CODES 66982 AND 66984

The following is the 2020 CPT description of code 66982:

According to the American Medical Association’s (AMA) publication titled CPT Changes 2001, An Insider’s View, the following rationale was originally given for this new code:

Thus, it is very important that the code only be used for cases that are deemed to be complex. It should not be used for coding when complications are encountered during cataract surgeries.

WITTING AND UNWITTING COMPLIANCE VIOLATIONS

Utilization. In 2015, Comparative Billing Report (CBR) audits were conducted by CMS wherein a comparison of an individual’s percentage of complex cataracts performed to national and state averages was made. Those who exceeded the averages were notified in a letter. Whereas the national societies were assured that CMS was not going to use the information for auditing—and it did not—outside agencies were subcontracted by CMS and started auditing practitioners for abusive use of CPT code 66982.

It would do well for cataract surgeons to perform a review of their percentage by dividing the number of complex procedures (# of 66982) performed (the numerator) by the total of all cataract extractions performed (# of 66982 + 66984). If the rate exceeds 10%, it would do well to consider an internal or external audit.

Use of Dye. The use of dye to stain the capsule, in and of itself, does not constitute a condition for coding the case as complex. The code intent is using dye in conjunction with removal of a mature, dense cataract is allowable as a condition for use of the complex code. Some LCDs that currently state, or previously stated, that the use of dye in itself qualifies a case to be coded complex are at fault and should not be followed because the national policy is therein violated. A policy that combines the phrasing “use of dye” with the presence of a mature or dense cataract often leads to an erroneous misinterpretation that the dye is the qualifier. This was never the intent of the code by definition and is nowhere found in any of the CPT publications.

In fact, in CPT Assistant, an AMA publication, in March of 2016 it is stated: “…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.” So the use of dye in and of itself does not constitute sufficient extra work or intensity to qualify the case as being coded complex, nor does it require significant extra time. Pupillary enlargement procedures. Whereas the CPT definition and CPT Insider’s elucidations enumerate conditions for coding a case as qualifying as complex, other qualifying usages for the complex code may vary with each MAC’s LCD. MAC policies generally do not include manual or viscoelastic pupillary stretching.

Use of a Malyugin Ring may qualify a case when there is a miotic pupil (pupillary measurements pre- and post-dilation are mandatory in the chart documentation); however, simply its use as a determining factor too often cannot be considered valid. Most residency programs train using them as a prophylactic measure when the case actually does not qualify as complex, and then the resident becomes a practitioner and continues the practice either from habit, security enhancement, or financial considerations. Pupillary measurements before and after dilation that show insufficient dilation are mandatory chart documentation in both the office and OR charts.

The following are guidelines in a personal communication from the main authority on this:

The clinical reason any capsular tension ring or other device is being used must be documented in both the chart and the operative note. Permanently placed capsular tension rings would qualify as complex.

I have audited and participated in this extensively, and find utilization rates up to 45% in newly minted ophthalmologists and seasoned ones as well. Most of these are attributable to use of Malyugin ring or dye use that was not documented or warranted.

Pharmacological assistance with pupillary dilation/maintenance is not one of the criteria for a case qualifying for being coded as complex (e.g., use of epi-Shugarcaine or Omidria [Omeros]).

Synechiolysis cannot be additionally billed and is bundled under the National Correct Coding Initiative (NCCI). The definition of 66982 includes “requiring devices or techniques not generally used in routine cataract surgery.” The intent of the code is to include any form of synechiolysis. Both codes 66984 and 66982 were bundled with the various synechiolysis codes in Version 7.3 of the NCCI effective July 1, 2001. Performing synechiolysis does qualify the case to be considered complex.

MANAGEMENT OF INTRAOPERATIVE COMPLICATIONS

Management of intraoperative complications, such as vitreous loss, iris prolapse, and dropped nucleus or IOL, does not qualify the case as complex. The original intent was that, for the most part, the complex cataract code 66982 should be used when the physician plans prospectively and documents that a complex cataract procedure is to be performed in the preoperative plan.

Pediatric (or other) cases cannot be coded with CPT code 66982 when an IOL is not inserted. An IOL must be inserted to use this code even though pediatric cataract extraction is more difficult that adult cataract extraction.

The use of high-tech instrumentation does not necessarily qualify the procedure to be complex. Examples would include use of “laser” technology, a Fugo blade for anterior capsulorrhexis, or performing a different method of ablation of the lens rather than phacoemulsification.

CONCLUSION

More often than not, the surgeon is aware that the case qualifies as complex in advance—and that should be documented in the office visit when the surgery is scheduled. Some physicians, by the nature of their practices, will have a higher percentage of these cases than others. In all instances, it is wise to have complete and precise chart documentation preoperatively and include documentation in the operative note itself.

Best corrected visual acuity of 20/25 or 20/30 and near vision issues that are wholly refractive do not support cataract surgery at all. In fact, most Medicare auditors would cite the surgeon for lack of medical necessity and deem the case not eligible for reimbursement. ■