Complex cataract surgery

Use CPT code 66982 for extraordinary cases, not just lengthy ones.

Following an especially lengthy and difficult cataract surgery, the surgeon expressed dismay and asked about additional reimbursement. The biller was aware of a CPT code for complex cataract surgery but wasn’t clear about its applicability, and she decided to investigate.

What did she learn about complex cataract surgery?

First described in 2002, CPT code 66982 is described as “Extracapsular cataract removal with insertion of intraocular lens prosthesis (one 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.”

This description applies to a variety of situations. A complex cataract surgery may be performed on a patient with pupils that do not dilate because of chronic parasympathomimetic drug use, scarring or trauma. In such cases, mechanical dilation of the pupil is necessary to enable the surgeon to extract the cataract and place an IOL.

This code may also apply when the surgeon is required to suture the haptics of an IOL or implant a capsular tension ring. It may also apply for pediatric patients or patients with a subluxated lens. Other procedures requiring additional instrumentation or added steps may also qualify (eg, use of indocyanine green or trypan blue dye prior to capsulorrhexis).

Use of this code will be judged on a case-by-case basis.

Some acceptable ICD-9 codes are 364.23 (lens-induced iridocyclitis), 366.20 (traumatic cataract), and 379.32 (subluxation of the lens). Check with your local Medicare carrier for a list of suitable ICD-9 codes.

The national payment rate for 66982 in 2006 is $909.54. Reimbursement is about 33% higher than the Medicare rate for regular cataract surgery with IOL (66984).

While it is tempting to do so, one should not use 66982 just because the case took more time than usual. For example, a case may be longer if a hard lens requires more phaco time. Also, some cases require unplanned anterior vitrectomy for surgical misadventures. The vitrectomy is bundled with cataract surgery under Medicare’s National Correct Coding Initiative edits and should not necessarily be considered complex. In addition, the implantation of an accommodative IOL instead of another IOL does not require any special steps or unusual techniques and does not qualify as complex surgery. Only if a procedure would otherwise be considered complex would it be appropriate to code 66982.

CPT 66982 applies to a small minority of cataract surgeries. Of all Medicare claims paid during 2004, complex cataract surgery accounted for just 3% of all cataract extractions with IOL. However, ophthalmic practices vary, and some surgeons may perform this procedure more frequently than others by virtue of serving an extraordinary population. Other surgeons may elect to avoid these difficult cases altogether and never report 66982.

Following her investigation, the biller concluded that an overlong case did not, in itself, justify the use of complex cataract surgery, but that additional surgical steps might justify higher reimbursement. Armed with a clearer understanding of this code, she met with the surgeon to review a number of operative reports that might warrant the use of 66982.