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Question: I have a report for a cataract surgery. The postoperative diagnosis is nuclear sclerotic and cortical cataract of the right eye. The physician listed the procedure as phacoemulsification with posterior chamber lens implantation.

Here is a portion of the procedure note:

A corneal paracentesis was placed and 0.25cc of 1% lidocaine non-preserved was injected into the anterior chamber. Viscoelastic was installed into the anterior chamber to deepen it. A 2.4 mm corneal incision was made temporally and the anterior chamber was entered.

A continuous curvilinear capsulorrhexis was performed using a bent cystotome needle and capsulorrhexis forceps. Hydrodissection of the lens nucleus was done using BSS. A phacoemulsification tip was introduced, and the lens was removed via phacoemulsification. Residual cortex was removed from the capsular bag with the irrigation/aspiration tip. Viscoelastic was installed into the anterior chamber to deepen it. The posterior capsule was polished. Then a 22.0 diopter posterior chamber lens model ETA Bausch and Lomb intraocular lens was inserted into the capsular bag. The lens was then rotated so that the hash marks on the IOL were parallel to the 170 degree meridian. Viscoelastic was removed from the anterior chamber using the irrigation/aspiration tip.

The wound was hydrated and found to be self-sealing. The eyelid speculum was removed. One drop of Timoptic 0.5% was placed into the conjunctival cul-de-sac, and the patient was taken to the Short Stay unit in stable condition.

The surgeon wants us to report 66982 for the procedure. However, I’ve reviewed the procedure notes multiple times, and I’m unsure if it qualifies as a complex cataract surgery. Can you help?

California Subscriber

Answer: The ophthalmologist’s procedure is a routine cataract surgery, and you’ll assign 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) to report the procedure.

Some coders may see certain terms, such as “continuous curvilinear capsulorrhexis was performed,” and select a complex cataract removal code like 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation). However, that is incorrect because the continuous curvilinear capsulorrhexis is a routine step during cataract surgery.

In fact, depending on the Medicare Administrative Contractor (MAC) jurisdiction, the payer policies can differ on what constitutes a complex cataract removal. For example, according to the Centers for Medicare & Medicaid Services (CMS) article, “>Billing and Coding: Cataract Surgery in Adults,” reporting 66982 cannot be “related to the surgeon’s perception of the surgical difficulty.” Complex cataract surgery documentation needs to include “clear justification” to meet the code descriptor requirements. An example of a reason for complex cataract surgery includes “the patient required suturing a posterior chamber intraocular lens because of insufficient capsular support,” according to the CMS article.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC