Surgery

A billing and coding guide to Complex Cataract Surgery

Increase your value by learning to recognize billable services.

By Riva Lee Asbell, Fort Lauderdale, FL

As a technician, scribe, administrative person, or billing and coding administrator, one your objectives should be identifying potentially billable services a physician may overlook. By mastering the rules of complex cataract surgery involving diagnoses, examination findings and planned surgical procedures, you will be in a unique position to assist in identifying these surgical cases and ascertaining the chart documentation supports the charge.

Identifying a Complex Cataract

CPT Definition: Following is the Current Procedural Terminology description of code 66982:

Extracapsular cataract removal with insertion of IOL prosthesis (one 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.

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

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 (eg, uveitis) and disease states (eg, 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.

So, it is important cases identified as complex meet these characteristics; cases should not be identified as complex when complications were encountered during surgery.

LCD determination: This article reflects Medicare coding regulations and other insurers may vary. For Medicare, if there is a Local Coverage Determination (LCD) that has been issued, even if it is retired, you will find it very helpful in identifying what qualifies as complex.

Clinical Diagnoses: Here are some of the clinical situations when the code can be used:

■ Dense white or brunescent cataracts being removed in conjunction with use of a dye.

■ Pupillary enlargement procedures. The precise procedures that would qualify for using this code depend on your Medicare Administrative Contractor’s (MAC) LCD.

■ Vitrectomies occasionally can be coded or billed as an additional procedure. If CPT code 67005, removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal, or 67010, subtotal removal with mechanical vitrectomy, is used, each is ordinarily bundled by the National Correct Coding Initiative. However, in pediatric cataract surgery, when a limited pars plana vitrectomy is performed, that may be billed additionally. It is recommended that modifier -52 be applied since this is really a limited pars plana posterior vitrectomy. Also, modifier –59 would also have to be used because of the recent bundles with all cataract and retina/vitreous procedures (except 66850 – lensectomy). Pediatric 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 description of the code was changed to remove “endocapsular rings” in 2001 since, technically, a device that does not have FDA approval cannot be included in CPT code descriptors. Now that some of these devices do have FDA approval their use would qualify the case to be coded using CPT code 66982.

Documenting the Case

Office Chart Documentation: In most cases, the surgeon will be aware the case has the potential or can currently be classified as complex. This should be documented in the Medical Decision Making and the Plan.

In addition, make sure all ancillary documentation is in place. The most glaring absences in EHR chart documentation are those that require a form or free text such as a form for documenting problems with Activities of Daily Living (ADL) or Interpretation and Report forms for diagnostic tests.

It is highly recommended you have periodic small internal and external audits to ensure compliance. Other proactive things you can do include making a checklist for pre-qualifying a case to use on each cataract extraction case deemed complex.

Operative Note Documentation: Let your physician know it is important to document the reasons a case is complex in both the operative note and the office note. When MediCare is auditing, often they will just pull the operative note from the facility. The documentation needs to be in both places. Various MACs have recommended this type of documentation. Palmetto GBA MediCare recommends, in addition to standard documentation, if the case is going to be coded as complex, to include “Indication for Complex Cataract Surgery: ____” as part of the operative note. Include the presence of this statement in the internal audit.

Conclusion – Benefits to Practice

Some physicians, by nature of their practices, will have a higher percentage of these cases than others. In all cases, it is wise to perfect chart documentation preoperatively and to include documentation in the operative note itself. Be sure to remember all the other details of cataract surgery management that need attention such as documentation of the problems the patient is having with ADL, use of proper coding and modifiers for the surgical procedures and diagnostic tests, and perfect office examination charting.

As always, practicing good medicine and good chart documentation benefits not only the practice, but also the ophthalmic professional in achieving a sense of professional satisfaction and pride in a job well done that benefits the patient. OP

CPT codes and descriptions are copyrighted by the American Medical Association.

Riva Lee Asbell is a nationally recognized consultant on coding and compliance issues. She can be reached at rivalee@aol.com or through her Web site: www.rivaleeasbell.com