Article - Billing and Coding: Complex Cataract Surgery: Appropriate Use and Documentation (A53047)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextCPTdefines 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 CPTcode 66982, is not related to the surgeons 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, wouldnotbe 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 CPTcode 66982:Insertion of iris retractors through additional incisionsMechanical expansion of the pupil using hooksCreation of a sector iridectomy with subsequent suture repair of iris sphincterUse of a Malyugian ring and multiple iris sphincterotomies created with scissors.The need to support the lens implant with permanent intraocular suturesPlacement of a capsular support ring necessary to allow secure placement of an intraocular lensPerformance of pediatric cataract surgery with intraocular lens insertionUse of intraocular dyes (e.g., trypan blue or indocyanine green) to stain the lens capsule in the setting of a mature cataractThe above list may not be all inclusive. If a claim is denied for CPT66982, 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 supportIndication for Complex Cataract Surgery: Intraoperative iris hooks were required to address a severely miotic pupilIndication for Complex Cataract Surgery: Trypan blue dye was needed to adequately visualize the lens capsule in the setting of a mature cataract