Advanced Search

Revenue Cycle Insider

Optometry/Ophthalmology Coding:

Does This Cataract Surgery Fall Under a Complex Procedure?

Published on Mon Dec 15, 2025

You’ve reached your limit of free articles. Already a subscriber? Log in.

Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:

Simple explanations of current healthcare regulations and payer programs
Real-world reporting scenarios solved by our expert coders
Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
Instant access to every article ever published in Revenue Cycle Insider
6 annual AAPC-approved CEUs
The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles of

December 2025

Pediatric Coding:
Test Your Pediatric Coding Capabilities
How closely did you pay attention to the topics covered this year? Regardless of your [...]

General Coding:
Code Wound Care Correctly With These Tips
Payer auditors are increasing their scrutiny of wound care reporting. Gena Cornett, CPC, CPB, CPCO, [...]

Orthopedic Coding:
Learn How to Identify and Code Winter Sports Injuries
Find out if all injuries require surgery. When the weather gets cold, winter sports enthusiasts [...]

Emergency Department Coding:
Code for Every (Square) Centimeter on Ulcer Debridement
Question: A patient with chronic venous insufficiency without varicosity reports to the emergency department (ED) [...]

Optometry/Ophthalmology Coding:
Correctly Report Corneal Tissue Transportation for Keratoplasty
Question: I’m new to ophthalmology coding, and I have a report for a keratoplasty procedure [...]

Urology Coding:
Look for These Documentation Clues to Keep Urinary Incontinence Claims Flowing
Know when it’s appropriate to query the provider. Urinary incontinence is one of the most [...]

Practice Management:
Empower Employees to Unplug
Question: Our physicians and nonphysician practitioners (NPPs) are great clinicians and truly care about their [...]

Optometry/Ophthalmology Coding:
Get Clarity on OCT Coding and Avoid These Pitfalls
Can you bill OCT separately for each eye? Find out. Since its introduction in the [...]

Oncology/Hematology Coding:
Don’t Confuse Unconfirmed With Uncertain in This Lung Cancer Encounter
Question: One of our patients has a history of right lung cancer. After a recent [...]

Primary Care Coding:
Look to Treatment Plan Changes When Considering Modifier 25 for New Patients
Question: An encounter note says a new patient was seen by a primary care physician [...]

Otolaryngology Coding:
Take This Advice for Coding Transtympanic Therapeutic Injections
Question: Our otolaryngologists commonly perform transtympanic therapeutic injections. The patient may need a single injection [...]

Technology & Innovation:
Use Telehealth to Treat Patients Affected by SDOH
Find out what barriers stand in the way of widespread adoption. Social determinants of health [...]

Primary Care:
Know the Ins and Outs of Transitional Care Management
Find billing tips for providing this crucial service for patients. Transitional care management (TCM) plays [...]

General Surgery Coding:
Round Out 2025 With a Surgical Pathology Coding Quiz
Do you remember what code to use for a gross examination only? Surgical pathology codes [...]

Otolaryngology Coding:
Get Up to Speed With Drug-Eluting Sinus Implant Coding
Use this handy decision tree for accurate billing documentation. Drug-eluting sinus implants, such as Propel [...]

Neurology & Pain Management Coding:
Brush Up on Chronic Care Management Codes
Do you know the differences between standard and complex chronic care management? Chronic care management [...]

Primary Care Coding:
Capture ‘Chronic’ Nature of Tonsilitis Diagnosis
Question: An 8-year-old patient has come in complaining of sore throat six times over the [...]

Diagnostic Radiology Coding:
Teach AI to Compare Mammogram Views, Part 2
Learn what a 0.96 AUC score means. The mammogram screening process captures X-ray pictures of [...]

Neurology & Pain Management Coding:
Code Every Service on This Headache Encounter
Question: The pain management (PM) specialist sees a new patient suffering from “horrible” headaches. The [...]

Path/Lab Coding:
Follow 3 Tips to Perfect Your Bone Marrow Pathology Exam Coding
Look to this advice to avoid overbilling. Bone marrow cases with multiple specimens and special [...]

Compliance:
Don’t Silo Your CDI Specialists From Your Coders, Part 1
As external audits increase, bolster your compliance by making sure your teams are working together. [...]

General Surgery Coding:
Use 11400-11446 Code Range for Dermal Lesion Excisions
Question: A surgeon excised a benign lesion from a patient’s left arm. The excised diameter [...]

Practice Management:
Follow State Law When Reporting Surgery Assistance
Question: What are the appropriate modifiers to append for providers who assist during surgeries? New [...]

Practice Management:
Center Your Revenue Cycle on People, Part 1
Prioritizing patient care and perspective can make your revenue cycle healthier. Even though your practice’s [...]

Compliance:
Keep These Reference Books and Resources On Hand
Question: I’m putting together a little in-house library for coders, billers, and our internal auditor. [...]

Urology Coding:
Add Modifier 50 for Bilateral Renal Tumor Ablations
Question: Over the past few months, I’ve had several op notes that show the urologist [...]

Oncology/Hematology Coding:
Get the Answers to Your Frequently Asked PIN Service Questions
Understand the difference between PIN and PIN-PS. Coders and billers in oncology still have a [...]

ICD-10-CM Coding:
Yule Be Smart to Review These Dangers of the Holidays Codes
Add “Knowing how to code these common situations” to your holiday prep checklist. During the [...]

ICD-10-CM Coding:
Use This Route When Coding Gout
Question: My coworker and I are trying to determine the reason for a claim denial [...]

Neurosurgery Coding:
Infection, Immunization Evidence Matter for This Encephalopathy Dx
Question: Encounter notes indicate that the neurosurgeon performed critical care on a 5-year-old patient with [...]

E/M Coding:
Check Thresholds for Critical Care Code Reporting
Question: Two critical care providers saw a patient on the same day. I reported 99291 [...]

Cardiology Coding:
Use Add-On Code +92972 Correctly
Question: I submitted a claim with 92972 to report a percutaneous transluminal coronary lithotripsy. However, [...]

Pediatric Coding:
Query for Cough Specificity
Question: I’m fairly new to pediatric coding and my practitioner only noted that the patient [...]

Anesthesia Coding:
Know Medicare Particulars for Radiologic Anesthesia Coding
Question: I’m reporting radiologic anesthesia services performed on a Medicare beneficiary and running into obstacles [...]

Anesthesia Coding:
Stay Up to Date With Acute Pain Management, Part 1
Find some expert tips for coding anesthesia pain management services. Acute postoperative pain management (POPM) [...]

Cardiology Coding:
Find Mitral Valve Repair Code Options
Question: A cardiologist performed a mitral valve repair. According to the documentation, they placed an [...]

Medicare Regulations:
Prepare for TEAM, Coming January 1
Hundreds of facilities are impacted nationwide. Are you part of this new mandatory model? Per [...]

Pulmonology Coding:
Boost Your Flu, COVID-19, and RSV Vaccine Coding Knowledge This Season
Learn what separates vaccines from monoclonal antibodies. Respiratory diseases are one of the biggest culprits [...]

Pediatric Coding:
Expertly Code This Eczema Case
Question: I’m unsure which ICD-10-CM code is appropriate based on the following notes from a [...]

Neurosurgery Coding:
Know All Spinal Decompression Types to Master Coding
Question: I’m new to neurosurgery coding, having spent the past few years coding for a [...]

Orthopedic Coding:
Use a Total Knee Arthroplasty Revision Code for a Poly Revision
Question: An orthopedic surgeon performed total knee arthroplasty revision where they placed a patella button [...]

Path/Lab Coding:
Wait to Match Surgical Pathology Level With Definitive Dx
Question: Our pathologist received a specimen that the op report identified as “soft tissue mass, [...]

ICD-10-CM Coding:
Become Familiar With Otitis Media Codes
Question: How can I distinguish the difference between and correctly code the conditions of otitis [...]

Compliance:
Prioritize Data Organization
Question: I’m going through past audits and finding them so hard to search, as codes [...]

Neurosurgery Coding:
3 Tips Help You Collect for Spinal Osteotomies
Don’t forget to check whether the surgeon used an anterior or posterior approach. When your [...]

Podiatry Coding:
Cast Off Doubt About Coding for Castings
Question: We have a practitioner specializing in foot and ankle care. Until now, they have been [...]

Technology & Innovation:
Learn Which Networks Are Designated QHINs for TEFCA
Question: In the article “Everything You Need to Know About Participating in the TEFCA,” [...]

Optometry/Ophthalmology Coding:
Does This Cataract Surgery Fall Under a Complex Procedure?
Question: I have a report for a cataract surgery. The postoperative diagnosis is nuclear sclerotic [...]

In Case You Missed It (RCI Bonus Content):
Lessons Learned From OIG Audits
Take to heart these lessons that others learned the hard way. In healthcare, every audit [...]

E/M Coding:
See How to Bill This NP Shared Service
Question: A doctor saw a patient with a nurse practitioner (NP). The NP recorded the [...]

Pulmonology Coding:
Report an Abnormality Without a Pathology Report
Question: A 47-year-old patient presented to our pulmonology practice with a chronic cough and blood [...]

Pulmonology Coding:
Avoid Coding Signs/Symptoms When a Diagnosis Is Confirmed
Question: A senior patient visited the emergency department (ED) with difficulty breathing, fatigue, and swollen [...]

Anesthesia Coding:
Navigate Metric Conversion for Successful J2003 Reporting
Question: How do I report the use of 2 cc of lidocaine used in an [...]

Orthopedic Coding:
Code This Colles’ Fracture Encounter
Question: A new patient was referred to an orthopedic practice with pain and swelling in [...]

Diagnostic Radiology Coding:
Clearly Code This Repeat Procedure
Question: I’m the newest coder in our radiology office and I’m confused about how I [...]

Medicare Regulations:
Organize a Template for Bariatric Surgery Claim Prep
Question: I now work for a surgeon who performs bariatric surgeries, and many of our [...]

General Coding:
Be Wary of Using Unlisted CPT® Codes
Question: I’m an auditor and found a claim with 99499 billed and denied. Is there [...]

General Surgery Coding:
Use 31805 for an Intrathoracic Tracheal Wound Repair
Question: A patient was transported to the emergency department (ED) following a severe car crash. [...]

Neurology & Pain Management Coding:
Remember Secondary Dx for These Huntington’s Patients
Question: A patient reports to the neurologist with a diagnosis of Huntington’s disease. Encounter notes [...]

Medicare Regulations:
Check Payer Policies for Consultation Codes
Question: A physician in my practice saw a patient who has Medicare, as well as [...]

Path/Lab Coding:
Go Unlisted for Single NGS Multiple Gene Analysis
Question: A provider ordered a full gene sequence analysis of BRCA2 plus a BRCA1 known [...]

Podiatry Coding:
Get the Skinny on Skin Substitute HCPCS Updates
Question: Are there any HCPCS Level II updates related to skin substitution codes coming in [...]

Podiatry Coding:
Stay Ahead of Audits in Your Office
And learn to perfect your podiatry modifier usage going into 2026. During her HEALTHCON Regional [...]

Diagnostic Radiology:
Familiarize Yourself With X{EPSU} Modifiers
Question: I’ve only been coding in radiology for a few months and I’m having a [...]

Emergency Department Coding:
Get Body Surface Area Correct Before Coding Burn Treatment
Question: A patient presents to the emergency department (ED) with second-degree burns to their head [...]

Gastroenterology Coding:
Learn How to Report Control of GI Bleed Following CRC Screening
Question: I have an op note for a second colonoscopy performed the day after the [...]

Gastroenterology Coding:
Locate the Code for Appendicitis With Localized Peritonitis
Question: A patient presented to the emergency department (ED) at 3 a.m. with severe abdominal [...]

Otolaryngology Coding:
Defer to Provider for Otitis Media Timeline Guidance
Question: My otolaryngologist documented otitis media with effusion for one patient and chronic otitis media with [...]

Emergency Department Coding:
Differentiate Modifiers 25 and 57 to Stay Compliant
The key for ED providers is to count the global days. When your emergency department [...]

Technology & Innovation:
Avoid Doubling Your Workload by Using Coding-Aware AI
Question: What’s the difference between coding-naive and coding-aware artificial intelligence (AI)? Revenue Cycle Insider Subscriber [...]

Ob-Gyn Coding:
Dive Deep Into Hysteroscopy Coding With This Guide, Part 2
Learn how to report IUD removal and reinsertion. In the first part of this [...]

Urology Coding:
Should You Use 40818 or 15240 for Buccal Mucosa Grafts?
Question: I have an operative note for a urethroplasty procedure where the surgeon harvested an [...]

E/M Coding:
Find Even More Tips for Distinguishing Inherent From Separate Services
Find out what information you need to append modifier 25 correctly and with confidence. Modifier [...]

Cardiology Coding:
Use These Tips for Coding Thrombolytic Therapy
Hint: There are 3 main types of thrombolytic therapy procedures. Thrombolytic therapy, or thrombolysis treatment, [...]

Ob-Gyn Coding:
Code This RFA Fetal Reduction C Section Scenario
Question: The patient had a radiofrequency ablation (RFA) fetal reduction of twin A at 18 [...]

Ob-Gyn Coding:
Be Careful on Prior Authorizations for PT for Pregnant Patients
Question: Payers are denying prior authorizations for our pregnant patients who are experiencing back pain, [...]

Oncology/Hematology Coding:
Look to This Scenario to Master Metastatic CSF Cancer Coding
Question: A patient had a lumbar puncture that showed metastatic breast cancer to the cerebrospinal [...]

Gastroenterology Coding:
Follow These CRC Testing Requirements to Bolster Your Claims – Part 2
Find out where you won’t find clear guidance. Correctly coding colorectal cancer (CRC) screenings is [...]

General Coding:
Appeal Insurance Denials and Get the Reimbursement You Deserve
Question: As a medical coder working in a neurosurgical practice, I often encounter frequent insurance [...]

View All