Article - Billing and Coding: Cataract Extraction (A56544)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the local coverage determination (LCD) for Cataract Extraction.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Pre or Postoperative CareIf there is no sharing of pre- or post-operative care, the surgeon should bill the CPT code(s) without the use of modifier(s) -54, -55 or 56. If the ophthalmologist shares post-operative care with another physician, modifier -54 (Surgical care only) must be appended to the procedure code for the operative date. Modifier -55 (Postoperative management only) must be appended for any dates of post-operative care.Anatomic ModifiersThe anatomic modifiers left (-LT) or right (-RT) should be appended to the procedure code.Cataract extractionWhen cataract extraction is necessary to affect an unimpeded view of the fundus for proper management of patients with disease of the posterior segment of the eye(s), physicians/providers must bill the appropriate cataract diagnosis code as primary and the posterior segment disease as the secondary diagnosis code.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The medical record and/or test results documenting medical necessity should be maintained and made available on request.If cataract extraction is performed due to anisometropia, the medical record must substantiate the presence of significant aniseikonia secondary to anisometropia arising from the first cataract extraction with IOL implant. The medical record must reflect that the aniseikonia is visually significant to the patient by documenting the patient's subjective complaints and must also document that anisometropia is present by determination of the refractive error in both eyes after the first cataract surgery.If cataract extraction is performed in order to visualize the fundus, the disease being treated must appear in the medical record, and the necessity for visualization must be described in the medical record.For CPT code 66982 and 66987,complex cataract extraction, to be reasonable and necessary, the procedure should require devices or techniques not generally used in routine cataract surgery. Please see examples below:The operative note indicates that a permanent intraocular suture or a capsular support ring was employed to place the intraocular lens in a stable position.The operative note indicates a capsular support ring was employed or an endocapsular support ring was used.The operative note indicates the use of micro iris hooks inserted through four (4) or more separate cornea incisions, use of an iris dilator device, synechiolysis utilizing pupillary stretch maneuvers creation of multiple sphincterotomies with scissors, a sector iridotomy with suture repair of iris sphincter was performed, or a permanent intraocular suture, capsular support ring, or endocapsular support ring was used.The operative note indicates dye was used to stain the anterior capsule.The operative note indicates Phacolytic glaucomaThe operative note indicates a primary posterior capsulorhexis was performedThe operative note or postoperative records indicate an extraordinary amount of work was involved in the preoperative or postoperative care.The operative note indicates an artificial prosthetic iris was placed in the eye.