Outpatient Facility Coding Alert

Published on Tue Sep 23, 2014 PDF

Don’t miss that extra $160 for after-cataract services.

Post-op complications after cataract surgeries can be difficult to code, but don’t shed tears over the challenge. The good news is airtight documentation and smart use of modifiers can help you gain your rightful reimbursement.

Watch Global Period When Correcting PCO 

An “after-cataract” or Posterior Capsule Opacification (PCO) is one of the most common problems following cataract surgery. In this condition, the residual lens epithelial cells, left behind during the original surgery, proliferate and migrate. The membrane behind the newly inserted intraocular lens thickens, blurring the patient’s vision. 

Diagnosis: The associated ICD-9 code for PCO is 366.53 (After-cataract, obscuring vision). In the ICD-10 system, this diagnosis code will change to H26.499 (Other secondary cataract, unspecified eye) along with three other extended options (H26.491 […right eye], H26.492 [….left eye], or H26.493 […bilateral]). 

The management: To treat after-cataracts, ophthalmologists incise the posterior capsule with a YAG (yttrium aluminum garnet) laser, allowing the capsule to contract and stop obstructing the passage of light to the retina. 

Cataract surgery procedures -- including 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique, complex, requiring devices or techniques not generally used in routine cataract surgery or performed on patients in the amblyogenic developmental stage), 66983 (Intracapsular cataract extraction with insertion of intraocular lens prosthesis [one stage procedure]) and 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [1 stage procedure]), manual or mechanical technique [eg, irrigation and aspiration or phacoemulsification]) -- have 90-day global surgical periods. You don’t need to include modifiers if the YAG procedure takes place more than 90 days after the original cataract surgery and the patient is not within a post-operative period for any other surgical procedure performed by your physician or group.

Modifier possibility: Ophthalmologists sometimes treat after-cataracts within the global period of the initial cataract surgery. In these cases, append 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) to 66821 (Discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [e.g., YAG laser] [one or more stages]) to break it from the 6698x global surgical packages. 

Be Equipped to Prove Medical Necessity 

Some payers are reluctant to pay 66821 claims within 90 days after cataract surgery and have local coverage policies that discuss when it would be appropriate to perform the procedure, so be prepared to prove medical necessity. For example, Medicare Part B carrier Palmetto GBA states, “This procedure is seldom indicated in less than three months post cataract surgery. If a claim is submitted for procedure 66821 within three months of cataract surgery, additional documentation will be requested.”

Catch: Even if you have documented the medical necessity of performing the YAG laser capsulotomy within 90 days of the initial cataract surgery, be prepared to lose 30 percent of the normal reimbursement. 

“When a return to the OR is needed during the global period, modifier 78 is used to show that it was due to complications,” explains Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager with Pershing Yoakley & Associates in Clearwater, Fla. “Modifier 78 stipulates that a new global period should not start, as the surgery is considered part of the post-op care. Therefore, only the intra-operative payment portion will be payable. The pre- and post-op periods remain as is for the initial procedure.”

As Chapter 12, Section 40.4.C of the Medicare Claims Processing Manual confirms, “When a CPT® code billed with modifier 78 describes the services involving a return trip to the operating room to deal with complications, carriers pay the value of the intra-operative services of the code that describes the treatment of the complications.”

Example: When the ophthalmologist performs a YAG capsulotomy within the global of cataract surgery, Medicare will not pay for the pre- and postoperative portion of the YAG procedure. The pre- and postoperative payment portion of the original cataract surgery, Medicare says, covers those services.

Therefore, the surgeon is only paid the inter-operative allowance attributed to the fee schedule since they are considered to have already been paid for the preoperative and postoperative portions, given that the global period stays the consistent with the original surgery, clarifies Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Here’s the payoff: The intra-operative portion of the global surgical package for 66821 is valued at 70 percent of the total RVUs (the pre-op is worth 10 percent, and the post-op is worth 20 percent).

Bill Once for Multiple Sessions

Scenario: How would you bill a patient who had cataract surgery two years ago on the left eye, then had cataracts removed from the right eye last month -- and then presented with a complaint related to after-cataracts in the left eye? It’s within the global for the surgery on the right eye, but since the after-cataracts are in the left eye, it’s not related to the latest surgery.

Answer: You have to report 66821 appended with modifiers 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) and LT (Left side) to show that this new procedure is not connected with the most recent cataract surgery.

The situation gets even more complex when the after-cataract takes more than one session to clear up. The phrase “one or more stages” appears in the description of 66821 and most other laser codes. This means you can only bill one laser procedure of the same code in a 90-day period on the same eye, because these codes are defined as for one or more treatments.