Complicated Coding Issues in Combined Lens and Retina Surgery
As an increasing number of vitreoretinal surgeons perform combined retina and lens procedures, the coding and compliance issues may be different from typical retina-only procedures. This review presents some of these issues along with suggestions for managing them when coding and billing Medicare.
NCCI BUNDLING ISSUES
Dealing with the code edit pairs found in the National Correct Coding Initiative entails using modifier -59 to break the bundles, which just happens to be always on the list of the Office of the Inspector General’s work plan each year. Just because a bundle can be broken does not mean it should be broken. So use the modifier judiciously.
- Modifier -58 was used with the first code because it represents a procedure that is more extensive than the original procedures.
- With the second code, modifier -59 is used to break the bundle. Modifier -79 is used because the procedure is unrelated to the prior surgery.
- Unless the bundle is broken, an ambulatory surgery center (ASC) will not be reimbursed for its facility fee for the cataract surgery and IOL.
Be aware that the latest revisions in cataract policies (local coverage determinations [LCDs]) for some Medicare administrative contractors (MACs) require that a formal form be filled out documenting the specific difficulties the patient is having with activities of daily living as a result of the cataract.
The newest version of LCDs from some of the MACs state that “cataract extraction may be covered during vitrectomy procedures if it is determined that the lens interferes with the performance of the surgery for far peripheral vitreoretinal dissection and excision of the vitreous base, as in cases of proliferative vitreoretinopathy, complicated retinal detachments, and severe proliferative diabetic retinopathy.” (National Government Services/State of New York) Always be sure to document this.
CODE SELECTION DILEMMAS
66850 vs 66852
Current Procedural Terminology (CPT) Code 66850 (Removal of lens material; phacofragmentation technique, mechanical or ultrasonic) (eg, phacoemulsification) vs CPT code 66852 (Removal of lens material; pars plana approach, with or without vitrectomy
CPT code 66850 is used when a lensectomy is performed in conjunction with a vitrectomy procedure solely due to CPT instructions. Most retina surgeons and their billers instinctively want to use 66852 because “pars plana approach” is incorporated into the description. There is occasional use for 66852 when coding for pediatric cataract removal. The code was developed for primary cataract extraction using a pars plana approach wherein incidental vitreous may be removed but a core or complete vitrectomy is not performed.
- Use 66850 for phacoemulsification procedures done in conjunction with vitrectomies (67036) when an intraocular lens (IOL) is not being placed.
- Use 66984 (phaco with IOL) or 66982 (phaco with IOL, complex) when an IOL is inserted in conjunction with a 67108 procedure. You will have to append modifier -59 to get paid for the cataract and IOL insertion when performed in conjunction with retinal detachment repair.
- Using code 66852 will result in denials of the code when coding combination vitrectomy surgeries because it is bundled with the vitrectomy codes.
65920 vs 67121 vs 66986 vs 66985
These CPT codes are for the removal of an IOL and its replacement:
65920. Removal of implanted material, anterior segment of eye
67121. Removal of implanted material, posterior segment; intraocular
66985. Insertion of IOL prosthesis (secondary implant), not associated with concurrent cataract removal
66986. Exchange of IOL
- Code 67121 was actually developed for removal of an IOL dislocated into the posterior segment.
- Use 66985 when you are inserting a secondary IOL without removal of an IOL and 66986 when you are exchanging an IOL and all the work is occurring in the anterior segment. The case below could alternatively be coded as 67108 + 66986 + 65920-59; however, it does not seem to me to describe the complexity as well.
COMPLEX RETINAL DETACHMENT and COMPLEX CATARACT EXTRACTION CODES
67113. Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic tractional retinal detachment, retinopathy of prematurity, retinal tear of greater than 90º), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens.
66982. Extracapsular cataract removal with insertion of intraocular lens prosthesis that requires 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 amblyopic developmental stage
These codes, as well as the 66984 + 67113 combination, are bundled and require the use of modifier-59 when used together. Both codes have mandatory requirements that must be fulfilled. Code 67113 requires vitrectomy and membrane peeling; code 66982 requires devices (includes capsular tension rings that are not mentioned in the description) or techniques not normally used in standard cataract extraction. Neither should be used for coding complications or just because the case is complicated or difficult—both codes assume that the surgeon (and chart documentation) used prospective planning and there was prior knowledge of the complexity for the most part.
TIPS FOR SUCCESS
It is critical to be aware of your MAC’s LCDs on cataract surgery, particularly any activities of daily living requirements or coding requirements.
When repairing a retinal detachment by vitrectomy (67108), do not code for removal of retained lens fragments unless there is different instrumentation from that used for the vitrectomy. Codes 67108 and 66850 are bundled, and the use of modifier-59 must be justified.
If undertaking a joint case with an anterior segment surgeon, do not use modifier-62 for co-surgeons; instead, each surgeon should code for the procedures he or she performed.
Riva Lee Asbell is the principal of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm located in Fort Lauderdale, FL. She may be contacted at RivaLee@RivaLeeAsbell.com.
CPT codes © 2013 American Medical Association