Cataract surgery is the most common procedure performed by ophthalmic surgeons and accordingly, the procedure accounts for a large volume of the claims that ophthalmology medical billing companies process. Becker’s ASC Review notes that the Medicare Payment Advisory Commission (MedPAC) reported that cataract surgery (with intraocular lens (IOL) insert, 1 stage) comprised 18.7% of 2016 surgical volume in ambulatory surgical centers, more than double the next most frequent procedure. As such, claim denials can have a negative impact on an ASC’s bottom line. Knowledge about the coding and general billing requirements for cataract procedures is crucial for ASCs to prevent denials and ensure optimal reimbursement.
Know the codes: Here are some of the main CPT codes for cataract extractions with and without implant:
- Extraction of lens and lens material:
- 66850 Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration
- 66920 Removal of lens material; intracapsular
- 66940 Removal of lens material; extracapsular (other than 66840, 66850, 66852)
- With implant:
- 66982 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (one 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 (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic development stage.
- 66983 – Intracapsular cataract with insertion of intraocular lens prosthesis (one stage procedure)
- 66984 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)
- 66985 – Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract extraction
- 66986 – Exchange of intraocular lens
The ICD-10 codes for cataract are H25-28 Disorders of the lens.
- H25.1 Age-related nuclear cataracts
- H26 Other cataract
- H27.1 Dislocation of lens
- H28 Cataract in diseases classified elsewhere
ASCs should review the operative report to determine which CPT and ICD-10 codes are most appropriate to report on the claim.
Understand what constitutes a complex cataract extraction: The Beckers ASC Review report cautions that the American Medical Association’s (AMA’s) definition of a complex cataract removal and the provider’s state’s local coverage determination (LCD) requirements may differ. This means that providers should know when CPT code 66982, which defines “complex” cataract extraction, can be reported. Understanding the guidelines for coding complex cataracts is especially important as this is an area under scrutiny by the Office of Inspector General.
The American Academy of Ophthalmology (AAO) replied to a question in March 2018, which clarifies this matter. The question was: “The physician removed a mature pediatric cataract, which required the use of trypan blue. The surgery involved an anterior approach using the vitrector, rather than pars plana capsulotomy. She did not insert an IOL as it was not indicated. What is the best CPT code?
The AAO states that CPT code 66982 is not appropriate in this case because no lens was implanted, and recommends using code 66850, 66920 or 66940 (based on the operative note).
A www.eyeworld.org article lists some of the surgical complications that would not qualify as complex cataract extraction as: iris prolapse, vitreous loss, choroidal hemorrhages, and dropped nuclei.
According to www.medicarepaymentandreimbursement.com, indications for the use of code 66982 include: pediatric cataract surgery, extraordinary work that may occur when there is extreme postoperative inflammation and pain, mature cataract requiring dye for visualization of capsulorrhexis, and pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens.
The Beckers ASC Review report provides additional tips for accurate cataract coding:
- Code based on the specific type of cataract: Cataracts can be age-related, senile, diabetic, etc. The code assigned should be based on the cataract type as indicated in the physician’s documentation. ASCs should communicate with the physician to ascertain the specific type of cataract if it is not mentioned in the documentation.
- Ensure payment for specialty IOLs: Not collecting money for specialty IOLs will leave money on the table. Medicare pays for several specialty lenses from various manufacturers. ASCs should verify with the carrier whether there is an allowance for the lens and if it is not, they can collect the payment for the lens from the patient, preferably prior to the procedure. Patients should be informed about their potential financial responsibility for their lens prior to scheduling their procedure.
- Avoid linking aqueous drainage devices insertions with a cataract diagnosis: There is no medical necessity for aqueous drainage devices such as an iStent or CyPass for cataracts. So linking these devices to a cataract diagnosis can lead to claims denial. The devices are specific to the treatment of glaucoma and should be captured separately.
Experienced coders in medical billing and coding companies are well-versed in the CPT and ICD-10 codes for ophthalmology. They will communicate with providers to get all the information necessary for coding cataract procedures correctly. The services of expert coders and billing specialists can go a long way in maximizing reimbursement for ASCs.