Ophthalmology and Optometry Coding Alert

Don’t assume that medical necessity is implied.

Cataracts are a prevalent issue, affecting more than half of all Americans over the age of 80. In most eye care practices, you’ll see cataract patients every day, requiring you to understand how to differentiate the cataract excision codes from one another.

Fortunately, six tips can help you nail down the right cataract code every time.

1. Understand the Basics About Cataracts

A cataract is an opacity or loss of clarity on the crystalline lens. Age-related or senile cataracts are most common in adults, but diabetes also contributes to the condition (when cataracts appear secondary to the disease process).

Pediatric cataracts are also a concern, and the condition can be caused by eye injury or in a toxic condition through drugs or a body process.

There are no nonsurgical medical treatments that can alleviate cataracts, so ophthalmologists perform cataract surgery to remove the opacified lens:

2. Know the Medical Necessity Rules

Medicare — and payers that follow Medicare guidelines — will cover the costs of medically necessary cataract surgery. For example, in its local coverage determination (LCD), Palmetto GBA, a Medicare Part B carrier, considers lens extraction medically necessary (and covered by Medicare) when one or more of these conditions exists:

1. Cataract causing symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function not correctable with a tolerable change in glasses or contact lenses, lighting, or nonoperative means resulting in specific activity limitations and/or participation restrictions including, but not limited to reading, viewing television, driving, or meeting vocational or recreational needs.
2. Concomitant intraocular disease (e.g., diabetic retinopathy or intraocular tumor) requiring monitoring or treatment that is prevented by the presence of cataract.
3. Lens-induced disease threatening vision or ocular health
4. High probability of accelerating cataract development as a result of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments such as external beam irradiation.
5. Cataract interfering with the performance of vitreoretinal surgery.
6. Intolerable anisometropia or aniseikonia, uncorrectable with glasses or contact lenses, exists as a result of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity).

Medicare will consider some conditions not covered in the above items based on the standard of care and other factors related to medical necessity, but you’ll need to seek coverage for those on a case-by-case basis by working with your payers.

Watch for: Your ophthalmic surgeon should not base their decision to perform surgery on lens opacity alone. Surgery is not deemed to be medically necessary purely on the basis of lens opacity in the absence of symptoms. Also, the Snellen visual acuity chart results should be documented and will be considered toward medical necessity — but they’re not enough on their own, Palmetto says.

“An evaluation of visual acuity alone can neither rule in nor rule out the need for surgery,” Palmetto says in its LCD, last updated in 2020. “Visual acuity should be recorded and considered in the context of the patient’s visual impairment and other ocular findings.”

3. Check the Documentation

The patient’s medical record must include specific documentation to support and justify the cataract surgery. For a visually symptomatic cataract, the record must contain:

• A statement that describes specific symptomatic impairment of visual function resulting in specific activity limitations. For example, “Ms. Smith is no longer able to drive due to opacity in both eyes.”
• The patient’s own words describing their condition. This makes the documen­tation real. For instance, “Mr. Caldwell says he is no longer able to see through his left eye, due to what he describes as a foggy, blurry sensation.”
• A statement or measurements showing that the patient’s visual impairment is not correctable with a tolerable change in glasses or contacts. Past exam findings included here would be helpful if the deficit has changed.
• A best-corrected Snellen visual acuity at distance under standard testing conditions.
• If there are coexisting ocular diseases, the medical record should indicate that the cataract is the primary cause of visual compromise.
• A statement that the patient desires surgical correction; that the risks, benefits, and alternatives have been explained; and that a reasonable expectation exists that lens surgery will significantly improve both the patient’s visual and functional status. It is very important to include specifics about the patient in this documentation.

4. More Specificity Means Avoiding Unspecified Diagnoses

The ICD-10 diagnosis codes for cataracts — those that will support medical necessity — are within the H25.011-H25.89 range for age-related cataracts and the H26.001-H26.8 range for other cataracts.

Most of these codes have six characters, which specify details such as the kind of cataract and the affected eye(s). With all the documentation requirements for billing, there should be no need to report the unspecified cataract codes H25.9 and H26.9.

5. 66982-66984 Are Common CPT^® Codes — but Watch for Audits

The most common CPT^® codes for cataract surgery are:

• 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)
• 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure))
• 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)

Keep in mind, however, that these are also among the most commonly audited codes for documentation compliance.

Watch for: Don’t report 66982 just because the ophthalmologist encountered a surgical complication, such as the need to perform a vitrectomy.

Report 66982 only if the ophthalmologist knows preoperatively that the procedure is necessary and meets the requirements of the code descriptor. Documentation in the medical record prior to the surgery will support this decision.

Other CPT^® codes you may encounter are:

• 66830 (Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy))
• 66840 (Removal of lens material; aspiration technique, 1 or more stages)
• 66850 (… phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration)
• 66852 (… pars plana approach, with or without vitrectomy)
• 66920 (… intracapsular)
• 66940 (… extracapsular (other than 66840, 66850, 66852))

Second eye: If a symptomatic cataract is present in both eyes, the surgeon will generally only perform the surgery on the first eye because of the potential for visual loss in both eyes. More commonly, the second cataract will be addressed after an appropriate interval has passed.

6. Don’t Forget PC- or AC-IOL Extras

Many cataract procedures include the insertion of an intraocular lens prosthesis. If the procedure is performed in a facility setting, you would not be able to code separately for the lens supply. However, in an office setting, Medicare allows you to report V2632 (Posterior chamber intraocular lens) for a conventional IOL.

If the patient receives IOLs that correct presbyopia or astigmatism, Medicare will still only pay the cost of a standard IOL; the patient will be responsible for the extra cost for the presbyopia or astigmatism correction.

You can code this extra portion with HCPCS code V2787 (Astigmatism correcting function of intraocular lens) for an astigmatism-correcting IOL (AC-IOL, also known as a toric IOL). Code the extra cost of a presbyoptia-correcting IOL (PC-IOL) with V2788 (Presbyopia correcting function of intraocular lens). Keep in mind, however, that this is only payable in an office. If the service is performed in an ASC or hospital, that facility will collect the fee.

Medicare will not pay the extra cost, so the responsibility for payment for V2787 or V2788 will ultimately fall to the patient.

Reporting V2787 or V2788 to Medicare is optional. The patient may ask you to do so in order to receive a denial that he can then submit to a secondary payer to receive payment. In that case, append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) to the V code.