Billing and Coding: Complex Cataract Surgery: Appropriate Use and
Documentation

CPT defines the code 66982 as: "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
developmental stage."  
  
The billing of CPT code 66982, is not related to the surgeon's perception of
the surgical difficulty. The use of this code is governed by the need to
employ devices or techniques not generally used in routine cataract surgery.  
  
For example, the presence of "pseudoexfoliation syndrome", which is known to
predispose to weaker lens zonules; and thus, to an increased risk for loss of
capsular support for an intraocular lens, would **not** be sufficient if the
zonular support was adequate and no special tools were employed. Similarly, a
particularly dense cataract that required extra time would not qualify.  
  
The need for hooks or other devices to address a particularly miotic pupil
would qualify, as would pediatric cataract surgery, which may be more
difficult intraoperatively because of an anterior capsule that is more
difficult to tear, cortex that is more difficult to remove, and the need for a
primary posterior capsulotomy or capsulorrhexis.  
  
Based on the definition and advice from ophthalmology groups, for clarity,
this A/B MAC specifically considers the need for the following to justify the
use of this CPT code 66982:

  * Insertion of iris retractors through additional incisions
  * Mechanical expansion of the pupil using hooks
  * Creation of a sector iridectomy with subsequent suture repair of iris sphincter
  * Use of a Malyugian ring and multiple iris sphincterotomies created with scissors.
  * The need to support the lens implant with permanent intraocular sutures
  * Placement of a capsular support ring necessary to allow secure placement of an intraocular lens
  * Performance of pediatric cataract surgery with intraocular lens insertion
  * Use of intraocular dyes (e.g., trypan blue or indocyanine green) to stain the lens capsule in the setting of a mature cataract

The above list may not be all inclusive. If a claim is denied for CPT 66982,
additional information should be submitted along with an appeal request. The
provider should include complete medical documentation (e.g., operative note)
to support the complex cataract extraction as well as a description of the
circumstance that justifies the use of the complex cataract extraction code.
This procedure must also meet the requirements of any current Local Coverage
Determination (LCD) for Cataract Surgery.  
  
Every complex cataract surgery must show justification. Therefore, it is
strongly recommended to include an initial supporting statement in the
operative note. For example:

  * Indication for Complex Cataract Surgery: The patient required suturing a posterior chamber intraocular lens because of insufficient capsular support
  * Indication for Complex Cataract Surgery: Intraoperative iris hooks were required to address a severely miotic pupil
  * Indication for Complex Cataract Surgery: Trypan blue dye was needed to adequately visualize the lens capsule in the setting of a mature cataract