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Billing and Coding: Cataract Surgery in Adults

A57195

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Article ID
A57195
Article Title
Billing and Coding: Cataract Surgery in Adults
Article Type
Billing and Coding
Original Effective Date
10/01/2019
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 §1862(a)(7) excludes routine physical examinations.

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

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

Code of Federal Regulations 42 CFR CH.IV [411.15(b)(2)&(3)and(o)(1)&(2)] Services excluded from coverage

Code of Federal Regulations 42 CFR CH. IV [416.65] Covered surgical procedures

CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §80.10, Phaco-Emulsification Procedure-Cataract Extraction

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

Article Guidance

Article Text

Documentation Requirements:

The following documentation must be present in the medical chart:

For Visually-Symptomatic Cataract:

  1. A statement indicating that specific symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function resulting in the patient's inability to function satisfactorily while performing Activities of Daily Life. Such activities would typically include, but are not limited to, reading, viewing television, driving, or meeting vocational or recreational expectations. The patient’s own words should be included in the statement where possible.
  2. A best-corrected Snellen visual acuity at distance (and near if the primary visual impairment is at near) as determined by a careful refraction under standard testing conditions as appropriate must be recorded to establish the inability to correct the patient's visual function with a tolerable change to glasses or contact lenses. Neither uncorrected visual acuity nor corrected acuity with the patient’s current prescription will satisfy this requirement. The refraction may be performed by the surgeon or by suitably trained staff in the surgeon’s practice as permitted by law.
  3. A degree of lens opacity that correlates with the impairment of best-corrected visual acuity when cataract is the primary cause of visual compromise.
  4. An attestation supported by documented symptoms and physical findings in the medical record indicating that the patient's impairment of visual function is believed not to be correctable with a tolerable change in glasses or contact lenses.
  5. When one or more concomitant ocular diseases are present that potentially affect visual function (e.g., macular degeneration or diabetic retinopathy), the attestation should indicate that cataract is believed to be significantly contributing to the patient’s visual impairment.
  6. 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 visual and functional status of the patient.

For Other types of Cataract:

  1. A statement indicating that the appropriate medical condition or circumstance exists and the specific reason for surgical intervention (e.g., “Cataract surgery is being performed to establish clear media for the treatment [or monitoring] of diabetic retinopathy).
  2. A statement that the patient desires surgical correction, that the risks, benefits, and alternatives have been explained, and that the patient understands that the surgery is being done to address the medical condition or circumstance. If vision is specifically not expected to improve, the statement should include the patient’s understanding of that fact.

For All types of Cataract:

  1. An appropriate preoperative ophthalmologic evaluation, which generally includes a comprehensive ophthalmologic exam (or its equivalent components occurring over a series of visits). Certain examination components may be appropriately excluded based on the specific condition and/or urgency of surgical intervention.
  2. Results and interpretation of specialized ophthalmic studies done for medically-necessary reasons unique to the patient’s situation.
  3. Results and interpretation of specialized ophthalmic studies that are not expected to be routinely performed for routine cataract surgery with clear statements of the reasons they are needed to establish or exclude medical necessity

For Complex Cataract Surgery (CPT code 66982):

CPT defines the code 66982 as: "Extracapsular cataract extraction 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 ended up being adequate and no special tools or techniques were employed during surgery. Similarly, a particularly dense cataract that required extra surgical time to address would not qualify.

Indications for use of the complex cataract surgery code include:

  1. Use of tools or techniques to address a pupil that will not dilate sufficiently to allow adequate visualization of the lens including:
  2. iris retractors placed through additional incisions;
  3. an expansion device (e.g. Beehler) or ring (e.g. Malyugin);
  4. a sector iridectomy with subsequent suture repair of the iris sphincter; and/or
  5. sphincterotomies created with scissors or other tools;
  6. Pediatric cataract surgery;
  7. Use of dye (e.g. trypan blue or indocyanine green) for visualization of the anterior capsule in the presence of a mature cataract;
  8. Use of permanent sutures to fixate an intraocular lens; and/or
  9. Use of capsular tension rings or segments to allow secure placement of an intraocular lens (e.g., in the presence of pre-existing zonular weakness); and/or need for creation of a primary posterior capsulorhexis.
  10. Every complex cataract surgery must have a justification to meet the requirements of its CPT descriptor. 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 presence of a mature cataract

Note that a procedure coded as "Complex Cataract Surgery" must meet all other requirements for Cataract Surgery as outlined.


Utilization Requirements

Medicare benefits include a conventional intraocular lens (IOL) following cataract surgery, facility supplies and physician services to implant the conventional IOL and one pair of glasses or contact lenses as a prosthetic device post-operative.

The following coding and billing guidance is to be used with its associated Local coverage determination.

Ancillary tests that are not routinely indicated in the preoperative workup for cataract surgery (see “Specialized Ophthalmic testing”) will not be considered a covered benefit if performed unless medical necessity is defended by a clear statement in the patient's record.

If an optometrist or an ophthalmologist who is not the surgeon performs biometry for intraocular lens power calculation, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary. If biometry is repeated by the operating surgeon due to inadequacy of the first study, the original eye care physician/provider should anticipate not being reimbursed for the study.


When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222, H26.223, H26.211, H26.212, H26.213, E08.36, E09.36, E10.36, E11.36, E13.36, 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, H26.8, coding guidelines require that the causative agent be identified on the claim.

 

 

Coding Information

CPT/HCPCS Codes

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Group 1

(11 Codes)
Group 1 Paragraph

N/A

 Group 1 Codes
CodeDescription
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 REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION
66852 REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY
66920 REMOVAL OF LENS MATERIAL; INTRACAPSULAR
66940 REMOVAL OF LENS MATERIAL; EXTRACAPSULAR (OTHER THAN 66840, 66850, 66852)
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
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
66988 EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITH ENDOSCOPIC CYCLOPHOTOCOAGULATION

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(112 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
H21.221 Degeneration of ciliary body, right eye
H21.222 Degeneration of ciliary body, left eye
H21.223 Degeneration of ciliary body, bilateral
H21.261 Iris atrophy (essential) (progressive), right eye
H21.262 Iris atrophy (essential) (progressive), left eye
H21.263 Iris atrophy (essential) (progressive), bilateral
H21.271 Miotic pupillary cyst, right eye
H21.272 Miotic pupillary cyst, left eye
H21.273 Miotic pupillary cyst, bilateral
H21.29 Other iris atrophy
H21.531 Iridodialysis, right eye
H21.532 Iridodialysis, left eye
H21.533 Iridodialysis, bilateral
H21.561 Pupillary abnormality, right eye
H21.562 Pupillary abnormality, left eye
H21.563 Pupillary abnormality, bilateral
H21.81 Floppy iris syndrome
H21.89 Other specified disorders of iris and ciliary body
H21.9 Unspecified disorder of iris and ciliary body
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
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
H26.111 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
H26.211 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
H26.411 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
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
H40.89 Other specified glaucoma
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

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

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

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.

CodeDescription
999x Not Applicable

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.

CodeDescription
99999 Not Applicable

Other Coding Information

N/A

Revision History Information

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

Under Article Text, corrected the typographical error to indicate 'For Complex Cataract Surgery (CPT code 66982) as it incorrectly listed CPT 66892.
01/01/2022 R3

Under CPT/HCPCS Codes: removed 66989 and 66991 due to being incorrectly added. These codes fall under another Noridian policy and to avoid confusion are being removed. 
01/01/2022 R2

Under Group I CPT codes add 66989 and 66991 per 2022 CPT coding update. 
01/01/2020 R1

01/01/2020: The Billing and Coding article for Cataract Surgery in Adults (LCD) is revised to add codes 66987 and 66988.

The following codes had descriptor changes in Group I coding: 66982 and 66984 

 

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