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12/11/2009

Using the Complex Cataract Surgery Code - 66982

Palmetto remains the Medicare contractor serving Ohio. The Ohio Ophthalmological Society (OOS) is frequently asked if the use of Epi-Shugar is sufficient to warrant the use of 66982 instead of 66984. Code 66982 is used to report the extracapsular cataract removal with insertion of intraocular lens 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 (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage. This procedure was recently discussed during a meeting of the Palmetto Contractor Advisory Committee (CAC).

Palmetto representatives admitted they are not in a position to tell ophthalmologists how to code their surgeries; however, they will defer to the advice of ophthalmology's own experts/specialists/organizing bodies for advice when considering whether a physician is using the code in a non-abusive (appropriate) way. The OOS now has a definite statement that Palmetto (Medicare) will defer to the American Academy of Ophthalmology's (AAO) position on the appropriate use of the complex cataract code.

We reviewed the AAO's website for information on reporting code 66982 and the following article was published in the March 2008 Coding Bulletin which can be found at http://www.aao.org/aaoesite/bulletins/Coding_200803.cfm Based on this information, the OOS realizes there is risk to physicians who are not aware of the AAO's advice and may be miscoding some of their surgeries. We are re-publishing the AAO coding instructions and encourage all ophthalmologists to review their current utilization of the complex cataract surgery code 66982.

Ask the Expert - What Constitutes Complex Cataract Surgery?

Sue Vicchrilli, COT, OCS, Academy Coding Executive

CPT description of 66982 reads Extracapsular cataract removal with insertion of intraocular lens 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 (eg, iris expansion device, suture support for intraocular lens or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage.

Medicare use of CPT code 66982 - commonly referred to as complex cataract surgery - almost doubled in the number of claim submissions between 2004 and 2006. With any significant increase in use, the increase in post-payment review audits will increase as well.

In the February edition of Coding Bulletin, I asked practices to submit surgical cases in question, which cases were then presented to the Academy Health Policy Committee members. The following is their response.

Physician work of 66982 is 40 percent greater than the typical case due to additional, significant work over the typical case.

The best guideline is to follow the state local coverage determination (LCD), of which there are only two. In the absence of an LCD, you can use your own criteria as long as it is reasonable. 

Case

Complex Cataract Surgery?

Floppy iris syndrome.

Yes if rings, hooks or pupil stretchers are done to manage it. No, if it is managed by adjusting machine flow rates, viscoelastics.

Piggy-back IOL

No

Traumatic cataract extraction, requiring planned intracapsular ring, without lens implant.

No. It is inappropriate to use a code with IOL implantation if you're not implanting an IOL.

 

Consider the family of 66840 to 66930 for this surgical case.

Using Healon GV and manually manipulating the pupil.

No. Use of a specific viscoelastic like Healon 5 or GV requires no more (or almost no more) work than use of regular viscoelastic - maybe an extra 30 seconds to make sure it is all aspirated.

The use of the Malyugin Ring.

Yes

If the pupil was "manually" manipulated with iris hooks but they weren't left in during surgery, would you consider this a complicated procedure

Yes. Preoperative chart documentation should include the size of the pupil before and after manipulation and the presence of posterior synechiae and the preoperative surgical plan for pupil expansion.

If the surgeon stretches the pupil but doesn't use iris hooks, is it complex?

Yes. Again, preoperative chart documentation should include the size of the pupil before and after manipulation and the presence of posterior synechiae and the preoperative surgical plan for pupil expansion.

The use of dye to stain the capsule for a hypermature cataract.

Yes - use of dye in a white or mature cataract necessary for capsulorrhexis.

 

Documentation of the reason for using Trypan Blue dye - such as mature, count fingers cataract, no red reflex, etc. - is strongly recommended.

An unplanned or planned vitrectomy at the time of cataract surgery.

No

Does a multi-focal lens qualify?

No

During the patient's exam, it is determined that he has been on Flomax therapy for a prostate problem. Clinical notes show 4+ NS and moderately severe floppy iris syndrome. The physician decides to use Shugarcaine intraoperatively to prevent complications from the floppy iris.

No


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