Local Coverage Article Billing and Coding

Billing and Coding: Complex Cataract Surgery: Appropriate Use and Documentation

A53047

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Contractor Information

Article Information

General Information

Article ID
A53047
Article Title
Billing and Coding: Complex Cataract Surgery: Appropriate Use and Documentation
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

Article Guidance

Article Text

CPT® defines the code 66982 as: "Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage."

The billing of CPT® code 66982, is not related to the surgeon’s perception of the surgical difficulty. The use of this code is governed by the need to employ devices or techniques not generally used in routine cataract surgery.

For example, the presence of “pseudoexfoliation syndrome”, which is known to predispose to weaker lens zonules; and thus, to an increased risk for loss of capsular support for an intraocular lens, would not be sufficient if the zonular support was adequate and no special tools were employed. Similarly, a particularly dense cataract that required extra time would not qualify.

The need for hooks or other devices to address a particularly miotic pupil would qualify, as would pediatric cataract surgery, which may be more difficult intraoperatively because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove, and the need for a primary posterior capsulotomy or capsulorrhexis.

Based on the definition and advice from ophthalmology groups, for clarity, this A/B MAC specifically considers the need for the following to justify the use of this CPT® code 66982:

  • Insertion of iris retractors through additional incisions
  • Mechanical expansion of the pupil using hooks
  • Creation of a sector iridectomy with subsequent suture repair of iris sphincter
  • Use of a Malyugian ring and multiple iris sphincterotomies created with scissors.
  • The need to support the lens implant with permanent intraocular sutures
  • Placement of a capsular support ring necessary to allow secure placement of an intraocular lens
  • Performance of pediatric cataract surgery with intraocular lens insertion
  • Use of intraocular dyes (e.g., trypan blue or indocyanine green) to stain the lens capsule in the setting of a mature cataract

The above list may not be all inclusive. If a claim is denied for CPT® 66982, additional information should be submitted along with an appeal request. The provider should include complete medical documentation (e.g., operative note) to support the complex cataract extraction as well as a description of the circumstance that justifies the use of the complex cataract extraction code. This procedure must also meet the requirements of any current Local Coverage Determination (LCD) for Cataract Surgery.

Every complex cataract surgery must show justification. Therefore, it is strongly recommended to include an initial supporting statement in the operative note. For example:

  • Indication for Complex Cataract Surgery: The patient required suturing a posterior chamber intraocular lens because of insufficient capsular support
  • Indication for Complex Cataract Surgery: Intraoperative iris hooks were required to address a severely miotic pupil
  • Indication for Complex Cataract Surgery: Trypan blue dye was needed to adequately visualize the lens capsule in the setting of a mature cataract

Coding Information

CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

The CPT® codes are considered medically necessary when the indications of coverage in the Cataract Surgery L34413 Local Coverage Determination (LCD) are met for surgical cataract treatment. A reasonable and necessary standard must be met for the utilized anterior segment drainage device.

Group 1 Codes
CodeDescription
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
66987 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; WITH ENDOSCOPIC CYCLOPHOTOCOAGULATION
66989 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; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE

CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2022 R9

Under CPT/HCPCS Codes Group 1: Paragraph added the verbiage “The CPT® codes are considered medically necessary when the indications of coverage in the Cataract Surgery L34413 Local Coverage Determination (LCD) are met for surgical cataract treatment. A reasonable and necessary standard must be met for the utilized anterior segment drainage device.” Under CPT/HCPCS Codes Group 1: Codes added 66989. This revision is due to the 2022 Annual CPT/HCPCS Code Update and is effective on January 1, 2022.

Under CMS National Coverage Policy added “Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.” This revision is effective on 1/1/22.

01/01/2020 R8

Under CPT/HCPCS Codes Group 1: Codes added CPT® code 66987. The code description was revised for CPT® code 66982. CPT® was inserted throughout the article where applicable. This revision is due to the Annual CPT®/HCPCS Code Update and becomes effective on 1/1/2020.

10/10/2019 R7

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles.

02/26/2018 R6 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
01/29/2018 R5 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
05/11/2017 R4 Under Article Text – corrected sentence CPT defines the code 66982 as: “Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage”.
10/01/2015 R3 Under Article Text general grammatical and punctuation changes were made throughout the article. The second paragraph was clarified. Removed “So” from the third paragraph, clarified the paragraph and transferred “Similarly, a particularly dense cataract that required extra time would not qualify.” from the fourth paragraph into the third paragraph. Combined “The need for hooks or other devices to address a particularly miotic pupil would qualify” from the fourth paragraph into the fifth paragraph. Combined paragraphs seven and eight. Removed paragraph nine based on the redundancy of information provided, since this information is expressed elsewhere in the article.
04/02/2015 R2 Made article into an A/B MAC article for consistency.
10/01/2015 R1 Under Article Text changed short descriptor for code 66982 to long definition. In fifth paragraph, beginning with "Pediatric cataract surgery" added "[which, based on the code description, must include insertion of an intraocular lens; see other codes in the series if a lens is not inserted]". In sixth paragraph, added "specifically". In seventh bullet, added "with intraocular lens insertion. In eighth bullet, added "in the setting of a mature cataract." Removed the statement "Additional defensible reasons can be considered on appeal should they not be accepted outright" and replaced with "The above list may not be all inclusive and if a claim is denied for CPT 66982, additional information may be submitted upon appeal with a description of the circumstance which the provider wishes for Palmetto GBA to consider as justification for the use of the complex cataract extraction code." In eighth paragraph, changed "the" to "any current" in reference to LCD on Cataract Surgery. In the last bullet of this section, added "in the setting of a mature cataract".

Associated Documents

Related Local Coverage Documents
LCDs
L34413 - Cataract Surgery
Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
12/29/2021 01/01/2022 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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