Local Coverage Article Billing and Coding

Billing and Coding: Cataract Surgery

A56613

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Contractor Information

Article Information

General Information

Article ID
A56613
Article Title
Billing and Coding: Cataract Surgery
Article Type
Billing and Coding
Original Effective Date
06/13/2019
Revision Effective Date
01/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
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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

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, §40.6 Claims for Multiple Surgeries and §40.7 Claims for Bilateral Surgeries

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cataract Surgery L34413.

When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222, H26.211, H26.212, H26.213, H26.221, H26.222, H26.223, E08.36, E09.36, E10.36, E11.36, E13.36 or H28 note that coding guidelines require that the ICD-10 code for the underlying condition must appear and be coded first on the claim. For ICD-10 codes H26.31, H26.32, H26.33 and H26.8, coding guidelines require that the causative agent be identified on the claim.

Coding Information

CPT/HCPCS Codes

Group 1

(13 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
66830 Removal of lens lesion
66840 Removal of lens material
66850 Removal of lens material
66852 Removal of lens material
66920 Extraction of lens
66940 Extraction of lens
66982 Xcapsl ctrc rmvl cplx wo ecp
66983 Cataract surg w/iol 1 stage
66984 Xcapsl ctrc rmvl w/o ecp
66987 Xcapsl ctrc rmvl cplx w/ecp
66988 Xcapsl ctrc rmvl w/ecp
66989 Xcpsl ctrc rmvl cplx insj 1+
66991 Xcapsl ctrc rmvl insj 1+

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(104 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract
E10.36 Type 1 diabetes mellitus with diabetic cataract
E11.36 Type 2 diabetes mellitus with diabetic cataract
E13.36 Other specified diabetes mellitus with diabetic cataract
H20.21 Lens-induced iridocyclitis, right eye
H20.22 Lens-induced iridocyclitis, left eye
H20.23 Lens-induced iridocyclitis, bilateral
H25.011 Cortical age-related cataract, right eye
H25.012 Cortical age-related cataract, left eye
H25.013 Cortical age-related cataract, bilateral
H25.031 Anterior subcapsular polar age-related cataract, right eye
H25.032 Anterior subcapsular polar age-related cataract, left eye
H25.033 Anterior subcapsular polar age-related cataract, bilateral
H25.041 Posterior subcapsular polar age-related cataract, right eye
H25.042 Posterior subcapsular polar age-related cataract, left eye
H25.043 Posterior subcapsular polar age-related cataract, bilateral
H25.091 Other age-related incipient cataract, right eye
H25.092 Other age-related incipient cataract, left eye
H25.093 Other age-related incipient cataract, bilateral
H25.11 Age-related nuclear cataract, right eye
H25.12 Age-related nuclear cataract, left eye
H25.13 Age-related nuclear cataract, bilateral
H25.21 Age-related cataract, morgagnian type, right eye
H25.22 Age-related cataract, morgagnian type, left eye
H25.23 Age-related cataract, morgagnian type, bilateral
H25.811 Combined forms of age-related cataract, right eye
H25.812 Combined forms of age-related cataract, left eye
H25.813 Combined forms of age-related cataract, bilateral
H25.89 Other age-related cataract
H25.9 Unspecified age-related cataract
H26.001 Unspecified infantile and juvenile cataract, right eye
H26.002 Unspecified infantile and juvenile cataract, left eye
H26.003 Unspecified infantile and juvenile cataract, bilateral
H26.011 Infantile and juvenile cortical, lamellar, or zonular cataract, right eye
H26.012 Infantile and juvenile cortical, lamellar, or zonular cataract, left eye
H26.013 Infantile and juvenile cortical, lamellar, or zonular cataract, bilateral
H26.031 Infantile and juvenile nuclear cataract, right eye
H26.032 Infantile and juvenile nuclear cataract, left eye
H26.033 Infantile and juvenile nuclear cataract, bilateral
H26.041 Anterior subcapsular polar infantile and juvenile cataract, right eye
H26.042 Anterior subcapsular polar infantile and juvenile cataract, left eye
H26.043 Anterior subcapsular polar infantile and juvenile cataract, bilateral
H26.051 Posterior subcapsular polar infantile and juvenile cataract, right eye
H26.052 Posterior subcapsular polar infantile and juvenile cataract, left eye
H26.053 Posterior subcapsular polar infantile and juvenile cataract, bilateral
H26.061 Combined forms of infantile and juvenile cataract, right eye
H26.062 Combined forms of infantile and juvenile cataract, left eye
H26.063 Combined forms of infantile and juvenile cataract, bilateral
H26.09 Other infantile and juvenile cataract
H26.101 Unspecified traumatic cataract, right eye
H26.102 Unspecified traumatic cataract, left eye
H26.103 Unspecified traumatic cataract, bilateral
H26.111 Localized traumatic opacities, right eye
H26.112 Localized traumatic opacities, left eye
H26.113 Localized traumatic opacities, bilateral
H26.121 Partially resolved traumatic cataract, right eye
H26.122 Partially resolved traumatic cataract, left eye
H26.123 Partially resolved traumatic cataract, bilateral
H26.131 Total traumatic cataract, right eye
H26.132 Total traumatic cataract, left eye
H26.133 Total traumatic cataract, bilateral
H26.20 Unspecified complicated cataract
H26.211 Cataract with neovascularization, right eye
H26.212 Cataract with neovascularization, left eye
H26.213 Cataract with neovascularization, bilateral
H26.221 Cataract secondary to ocular disorders (degenerative) (inflammatory), right eye
H26.222 Cataract secondary to ocular disorders (degenerative) (inflammatory), left eye
H26.223 Cataract secondary to ocular disorders (degenerative) (inflammatory), bilateral
H26.231 Glaucomatous flecks (subcapsular), right eye
H26.232 Glaucomatous flecks (subcapsular), left eye
H26.233 Glaucomatous flecks (subcapsular), bilateral
H26.31 Drug-induced cataract, right eye
H26.32 Drug-induced cataract, left eye
H26.33 Drug-induced cataract, bilateral
H26.40 Unspecified secondary cataract
H26.411 Soemmering's ring, right eye
H26.412 Soemmering's ring, left eye
H26.413 Soemmering's ring, bilateral
H26.491 Other secondary cataract, right eye
H26.492 Other secondary cataract, left eye
H26.493 Other secondary cataract, bilateral
H26.8 Other specified cataract
H26.9 Unspecified cataract
H27.10 Unspecified dislocation of lens
H27.111 Subluxation of lens, right eye
H27.112 Subluxation of lens, left eye
H27.113 Subluxation of lens, bilateral
H27.121 Anterior dislocation of lens, right eye
H27.122 Anterior dislocation of lens, left eye
H27.123 Anterior dislocation of lens, bilateral
H27.131 Posterior dislocation of lens, right eye
H27.132 Posterior dislocation of lens, left eye
H27.133 Posterior dislocation of lens, bilateral
H28 Cataract in diseases classified elsewhere
H59.021 Cataract (lens) fragments in eye following cataract surgery, right eye
H59.022 Cataract (lens) fragments in eye following cataract surgery, left eye
H59.023 Cataract (lens) fragments in eye following cataract surgery, bilateral
Q12.0 Congenital cataract
Q12.1 Congenital displaced lens
Q12.2 Coloboma of lens
Q12.4 Spherophakia
Q12.8 Other congenital lens malformations
Q12.9 Congenital lens malformation, unspecified

Group 2

(56 Codes)
Group 2 Paragraph

The following codes may be used as codes to justify a cataract lens removal when the cataract density does not appear to justify the extraction. Appropriate documentation is expected to be maintained in the medical record.

 ICD-10 codes H40.51X1, H40.51X2, H40.51X3, H40.51X4, H40.52X1, H40.52X2, H40.52X3, H40.52X4, H40.53X1, H40.53X2, H40.53X3 and H40.53X4 require a secondary diagnosis.


Group 2 Codes
CodeDescription
H40.031 Anatomical narrow angle, right eye
H40.032 Anatomical narrow angle, left eye
H40.033 Anatomical narrow angle, bilateral
H40.061 Primary angle closure without glaucoma damage, right eye
H40.062 Primary angle closure without glaucoma damage, left eye
H40.063 Primary angle closure without glaucoma damage, bilateral
H40.10X2 Unspecified open-angle glaucoma, moderate stage
H40.10X3 Unspecified open-angle glaucoma, severe stage
H40.1110 Primary open-angle glaucoma, right eye, stage unspecified
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.1113 Primary open-angle glaucoma, right eye, severe stage
H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage
H40.1120 Primary open-angle glaucoma, left eye, stage unspecified
H40.1121 Primary open-angle glaucoma, left eye, mild stage
H40.1122 Primary open-angle glaucoma, left eye, moderate stage
H40.1123 Primary open-angle glaucoma, left eye, severe stage
H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage
H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified
H40.1131 Primary open-angle glaucoma, bilateral, mild stage
H40.1132 Primary open-angle glaucoma, bilateral, moderate stage
H40.1133 Primary open-angle glaucoma, bilateral, severe stage
H40.1134 Primary open-angle glaucoma, bilateral, indeterminate stage
H40.2211 Chronic angle-closure glaucoma, right eye, mild stage
H40.2212 Chronic angle-closure glaucoma, right eye, moderate stage
H40.2213 Chronic angle-closure glaucoma, right eye, severe stage
H40.2214 Chronic angle-closure glaucoma, right eye, indeterminate stage
H40.2221 Chronic angle-closure glaucoma, left eye, mild stage
H40.2222 Chronic angle-closure glaucoma, left eye, moderate stage
H40.2223 Chronic angle-closure glaucoma, left eye, severe stage
H40.2224 Chronic angle-closure glaucoma, left eye, indeterminate stage
H40.2231 Chronic angle-closure glaucoma, bilateral, mild stage
H40.2232 Chronic angle-closure glaucoma, bilateral, moderate stage
H40.2233 Chronic angle-closure glaucoma, bilateral, severe stage
H40.2234 Chronic angle-closure glaucoma, bilateral, indeterminate stage
H40.231 Intermittent angle-closure glaucoma, right eye
H40.232 Intermittent angle-closure glaucoma, left eye
H40.233 Intermittent angle-closure glaucoma, bilateral
H40.241 Residual stage of angle-closure glaucoma, right eye
H40.242 Residual stage of angle-closure glaucoma, left eye
H40.243 Residual stage of angle-closure glaucoma, bilateral
H40.51X1 Glaucoma secondary to other eye disorders, right eye, mild stage
H40.51X2 Glaucoma secondary to other eye disorders, right eye, moderate stage
H40.51X3 Glaucoma secondary to other eye disorders, right eye, severe stage
H40.51X4 Glaucoma secondary to other eye disorders, right eye, indeterminate stage
H40.52X1 Glaucoma secondary to other eye disorders, left eye, mild stage
H40.52X2 Glaucoma secondary to other eye disorders, left eye, moderate stage
H40.52X3 Glaucoma secondary to other eye disorders, left eye, severe stage
H40.52X4 Glaucoma secondary to other eye disorders, left eye, indeterminate stage
H40.53X1 Glaucoma secondary to other eye disorders, bilateral, mild stage
H40.53X2 Glaucoma secondary to other eye disorders, bilateral, moderate stage
H40.53X3 Glaucoma secondary to other eye disorders, bilateral, severe stage
H40.53X4 Glaucoma secondary to other eye disorders, bilateral, indeterminate stage
H40.89 Other specified glaucoma
H52.31 Anisometropia
H53.2 Diplopia

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

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

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.

N/A

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.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2022 R4

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 and 66991. This revision is due to the 2022 Annual CPT/HCPCS Code Update and is effective on January 1, 2022.

01/01/2020 R3

Under CPT/HCPCS Codes Group 1: Codes added CPT® codes 66987 and 66988. The code descriptions were revised for CPT® codes 66982 and 66984. This revision is due to the Annual CPT®/HCPCS Code Update and becomes effective on 1/1/2020.

10/10/2019 R2

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. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Cataract Surgery L34413 LCD and placed in this article.

06/13/2019 R1

All coding located in the Coding Information section has been removed from the related Cataract Surgery L34413 LCD and added to this article.

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
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Keywords

  • Cataract