Avoid Confusing PCO Treatment With Cataract Surgery
Can you report YAG capsulotomy and cataract surgery on the same DOS? Sometimes, a cataract surgery patient returns to the practice with the complaint that vision in the treated eye has become cloudy again. The patient may assume that the cataract has returned, and an ophthalmology coder might assume that the subsequent procedure should be treated as another cataract surgery. Be careful, however: The patient’s assumption might lead to sleepless nights, and the coder’s assumption could lead to denied or delayed claims. Consider: The ophthalmologist is likely to suspect a common long-term side effect of cataract surgery, posterior capsule opacification (PCO) or “secondary cataract,” is causing the patient’s cloudy vision. PCO occurs when cells remaining after cataract surgery cause the posterior portion of the lens capsule — which would have been left intact to hold the patient’s new inserted lens — to become cloudy, interfering with light reaching the retina. The good news for the patient is that this common side effect is easily treatable with an in-office procedure. And the good news for coders is that understanding the procedure and proper documentation can lead to more accurate coding and successful claims. Start With 66821 To treat PCO, ophthalmologists need to create an opening in the cloudy posterior capsule to let light once again reach the retina and restore the patient’s visual pathway. This is known as YAG laser capsulotomy. The procedure is done with a solid-state laser equipped with a neodymium-doped yttrium aluminum garnet (Nd:YAG) crystal. First step: Report 66821 (Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser)(1 or more stages)) for laser surgery used to treat a secondary membranous cataract. Distinction: Unlike cataract extraction, YAG capsulotomy does not remove the eye’s natural lens and replace it with an intraocular lens (IOL); that already occurred during the earlier cataract surgery, with the posterior portion of the lens capsule left to hold the IOL. The laser treats the remaining capsule segment’s opacification (clouding). Keep that difference in mind when selecting a diagnosis code. Depending on payer policy and the documented condition, appropriate ICD-10-CM codes for post-cataract secondary opacity may include the following: Remember: Don’t default to the diagnosis code (most likely from the H25.- [Age-related cataract] family) that supported the original cataract extraction. Code the condition the ophthalmologist is treating now based on the documentation and the payer’s coverage policy. Prove Necessity With More Presence of PCO Alone A PCO finding does not automatically establish medical necessity for YAG capsulotomy. The record should demonstrate that the condition is affecting the patient’s vision or visual function sufficiently to warrant treatment. Documentation may include the following: The documentation should include pertinent examination or testing results that support the physician’s assessment. The connection between the patient’s complaint, the PCO, and the decision to perform the procedure should be apparent from the record. Watch the Cataract Surgery Global Period The timing of the appearance of symptoms and the ensuing YAG procedure also matters. The initial cataract code (for example, 66984 [Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation]) includes payment for many routine postoperative services and procedures done within 90 days of that procedure, such as in-office follow-up exams and management of typical post-op complaints that do not require a return to the operating room. Untangle the bundle: The National Correct Coding Initiative (NCCI) bundles YAG capsulotomy into the cataract surgery codes, which means that any separate report of 66821 on the same eye on the same date of service as 66984 is prohibited by default. If the capsulotomy happens within the 90-day global period, make sure your documentation supports that the procedure was unplanned and occurred after the date of the original surgery — and append the appropriate modifier to describe the clinical situation. If the same physician performs YAG capsulotomy on the same eye during the postoperative global period for cataract surgery, determine whether a global surgery modifier is required under the payer’s rules. Modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) identifies an unplanned return to the procedure room by the same provider for a related procedure during the post-op period. Check this: Make sure the operative note for the original cataract procedure does not mention a plan for a later YAG procedure. Don’t miss: Not every YAG procedure will require modifier 78, especially if it occurs after the 90-day global period expires or is not performed on the eye that was previously treated. Also, you’ll append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) if the same doctor, or a different doctor of the same specialty in the same group, performed a YAG capsulotomy on the opposite eye. But, as always, checking with the payer is never a bad move. Code This Unilateral YAG Capsulotomy Example Scenario: A patient underwent right-eye cataract extraction six months ago. The patient now reports worsening glare and blurred vision in that eye. Following an examination, the physician documents visually significant PCO in the right eye, and the ophthalmologist performs YAG capsulotomy. In this case, you’ll report the following: Because the original cataract procedure occurred six months earlier, the coder does not have the cataract surgery global period to contend with. The documentation establishes both the condition being treated and its effect on the patient’s vision. Examine This Bilateral Treatment Example Scenario: A patient who previously underwent cataract surgery in both eyes develops visually significant bilateral PCO. The physician documents impaired visual function attributable to the opacification and performs YAG capsulotomy on both eyes during the same session. Depending on payer requirements, report 66821 appended with modifier 50 (Bilateral procedure) for the bilateral YAG capsulotomy, supported by H26.493 for the bilateral secondary cataract. If the eyes are treated on different dates instead, report the appropriate RT or LT (Left side) modifier for the eye treated on each date and use the corresponding laterality-specific diagnosis codes. Watch for These Common Denial Triggers YAG capsulotomy claims may run into trouble when the record or claim does not clearly tell the story. Common vulnerabilities include: Medicare guidance indicates that post-cataract YAG capsulotomy generally should not require repeated treatment of the same eye, making clear documentation particularly important when another procedure is performed. Keep the Clinical Story Straight The easiest way to avoid confusion is to remember that cataract extraction and YAG capsulotomy address different problems at different stages of treatment. Cataract surgery removes an opacified natural lens and generally replaces it with an IOL. YAG capsulotomy treats a later opacity of the capsule left behind after that surgery. When the diagnosis, laterality, timing, and documentation all reflect that distinction, coders are in a much better position to demonstrate medical necessity, and keep an otherwise straightforward YAG capsulotomy claim from becoming an avoidable denial. Jerry Salley, BA, MFA, Contributing Writer
