Ambulatory Surgical Centers (ASCs) face different considerations in surgical coding and billing compared to physician surgical billing.1 This ASC checklist (Figure 1) enables facility staff to proficiently code even the most complex ASC surgical cases with confidence. A case example is provided to illustrate how to apply each item in the checklist.
Coding Case Example
The operative report describes a cataract surgery and Hydrus Microstent (Alcon) implant procedure on a patient with a combined form cataract patient and moderate primary open-angle glaucoma in the right eye with no complications. The documentation also notes that dye was used to stain the anterior capsule.
The initial step on the ASC coding and billing checklist emphasizes securing prior authorization for all anticipated procedure codes. While obtaining prior authorization does not guarantee payment, its absence guarantees nonpayment. For cataract surgery, it is advisable to seek prior authorization for the associated complex cataract surgery codes. The subsequent checklist item is closely intertwined with the first and often occurs concurrently.
The list of all appropriate codes for this case based on the information on hand include:
66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 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 ... or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation
66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis ... manual or mechanical technique ... without endoscopic cyclophotocoagulation
66989 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-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 ... or performed on patients in the amblyogenic developmental stage; with insertion of intraocular ... anterior segment aqueous drainage device, without extraocular reservoir, internal approach...
66991 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); with insertion of intraocular ... anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more
0671T Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more
When reading the full description and comparing what is in the operative report, it is possible to eliminate the standalone cataract surgery codes 66982 and 66984 as well as the standalone microinvasive procedure (MIGS) code 0671T and focus on identifying the combination code of 66989 (for complex cataract surgery plus MIGS) or 66991 (for standard cataract surgery plus MIGS).
Payers have different coding and billing requirements for each surgical procedure. The American Academy of Ophthalmology (AAO) provides checklists to their members for some of the most common ophthalmic surgical procedures that cover most payer’s requirements. AAO’s cataract surgery documentation checklist, which can be accessed by members at www.aao.org/cataract-surgery, includes frequently audited and missing items such as:
• A clear statement of the decreased ability to carry out specific activities of daily living
• Visual acuity and best-corrected vision by manifest refraction
• A physician assessment that a tolerable change in glasses will not improve the patient’s vision
Medicare Administrative Contractors (MACs) typically publish their Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs), which outline coding and billing requirements, on their websites. A list of MACs with links to these documents can also be found at www.aao.org/lcds. Commercial payers may provide published policies on their website or provider manuals.
ASC’s need to have a way to verify that all the payer required documentation is recorded in the patient’s chart. Failure to perform and/or document any payer’s requirements may result in a denial or recoupment during an audit if payment was made for both the physician and facility claim.
Not all MACs and commercial payers maintain a LCD for complex cataract surgery. However, for those who do, the indications are consistent and may include:
• A miotic pupil that will not dilate sufficiently and requires use of a mechanical iris expansion device (e.g., iris retractors through four additional incisions; Beehler expansion device; or Malyugin ring)
• Preexisting zonular weakness requiring use of capsular tension rings or segments, or intraocular suturing of the intraocular lens
• Pediatric cataract surgery
• Mature cataract (with use of correct ICD-10) requiring dye for visualization of capsulorrhexis
It is recommended to verify policy details directly with the specific payer.2
With this information, the appropriate code selection from the list of all relevant codes for this case is CPT 66991. The use of dye in the absence of a mature cataract diagnosis does not support a complex cataract procedure code.
Listing the procedure codes in order of highest to lowest allowable and checking for National Correct Coding Initiatives (NCCI) or bundling edits are crucial steps for surgical procedures with multiple surgical procedure codes. Not all procedures that are performed are reimbursable when performed with other procedures; some are bundled together. It is important to recognize that ASC NCCI edits might vary from physician NCCI edits regarding the application of modifier -59. Refer to payer-specific guidelines to guarantee the correct application of this modifier.3
Listing surgical codes in order of highest allowable ensures that reimbursement will be appropriately maximized as the first CPT code listed on the claim form is paid at 100% of its allowable, and subsequent codes will be paid at 50% of their allowable.
Appending modifiers in ASC surgical coding and billing is less complex than in physician coding and billing due to global surgical period considerations. However, neglecting them will lead to reimbursement issues.
Appropriate ICD-10 diagnosis codes linked to the procedure code support the medical necessity of that surgical procedure. H25.811 - Combined forms of age-related cataract, right eye and H40.1112 - Primary open-angle glaucoma, right eye, moderate stage are both necessary for the cataract and MIGS combination procedure code, CPT 66991.
Ensuring alignment between CPT code and ICD-10 diagnosis code selection is imperative for consistency in claims submitted by physicians and facilities. Discrepancies in coding and billing practices between the two entities may raise concerns among payers, potentially prompting increased payer scrutiny.
Finally, thoroughly review and submit the claim, closely monitoring the remittance advice for accurate reimbursement. By following the checklist steps, ASCs can improve accuracy, streamline billing, and optimize reimbursement for surgical procedures. OASC
REFERENCES
1. Billing for Ophthalmic Surgery: 10 Steps for Successful Coding. American Academy of Ophthalmology. Accessed December 5, 2023. https://www.aao.org/eyenet/article/billing-for-surgery-10-steps-for-successful-coding?june-2022
2. Baugh M. Coding Complex Cataract Cases. The Ophthalmic ASC. May 2023. Accessed January 3, 2023. https://digital.ophthalmologymanagement.com/articles/coding-complex-cataract-cases
3. Baugh M. ASC Surgical Modifiers Made Easy. The Ophthalmic ASC. August 2023. Accessed January 3, 2023. https://digital.glaucomaphysician.net/publication/?i=797071&article_id=4610312&view=articleBrowser
