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Learn what is needed to report ATIOLs and other procedures to correct cataracts.

Last month, Revenue Cycle Insider examined cataract surgery coding in the first article of this two-part series. In part 2, we’ll explain the different intraocular lens (IOL) types, examine and define various surgeries beyond traditional extraction and lens replacement, and review surgeries that may be required after the completion of cataract surgery. 

Identify Which Lens is Inserted

CPT^® codes for cataract surgery include a conventional intraocular lens (IOL). While a standard implant is recognized by payers as part of the procedure, the patient may still require glasses for their best vision. Technological advancements in recent years have introduced lenses to correct astigmatism (toric) lenses, presbyopic (multifocal) lenses, or light adjustable lenses (LAL), known collectively as Advanced Technology Intraocular Lenses (ATIOLs).

ATIOLs are premium lenses, considered to be an elective upgrade, and generally not reimbursable by insurance. Patients pay out of pocket for these lenses and should understand that their payer may not cover the cost; it is a fortunate patient who has coverage for ATIOLs. Therefore, Medicare patients sign an advance beneficiary notice (ABN) when choosing a premium lens upgrade. Commercial plans vary, and your patient would sign a notice of exclusion from health plan benefits (NEHB) or another waiver as dictated by their plan. 

In the rare event a lens needs to be submitted to insurance, HCPCS Level II code V2787 (Astigmatism correcting function of intraocular lens) indicates a toric or LAL lens or V2788 (Presbyopia correcting function of intraocular lens) is designated for a presbyopic lens. You’ll append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) or GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) to the corresponding HCPCS Level II code based on the circumstances and payer. Medicare should not be billed unless the patient specifically requests it. Commercial plans vary and benefits should always be verified, as rules for billing will differ from payer to payer.

Understand When a Cataract Surgery Is not a Cataract Surgery

Instances exist when a cataract procedure is not as cut and dry as extracting a cloudy natural lens and replacing it with an artificial lens. A cataract might be removed without placement of an IOL, which could be pre-decided or could occur due to a complication during a standard procedure. A surgeon might place an IOL where a lens was removed in an earlier procedure. An implanted IOL may have shifted, or it might need to be fully removed and replaced.

Assign 66850 ( Removal of lens mateRemoval of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration) when the phacoemulsification technique is employed on a cataract without concurrent placement of a lens.

If an IOL is placed at a separate procedure, use 66985 (Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal). Don’t forget to append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to denote a planned related procedure if the lens is placed within 90 days of the original extraction.

As the lens capsule naturally contracts, an IOL may become displaced. Code 66825 (Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure)) indicates entry through an incision to manipulate and return the IOL to the proper position within the eye.

A full IOL replacement may be required for several reasons: the IOL was poorly placed at time of implant or has shifted too far to be repositioned, the power was miscalculated resulting in refractive errors, or the IOL was defective. Code 66986 (Exchange of intraocular lens) encompasses both removal of the faulty IOL and placement of a new IOL. Be sure to append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to 66986 for an unplanned return to surgery if performing this exchange in the global period of the original surgery.

Report Additional Procedures After the Surgery

After placement of an IOL, the lens capsule will sometimes develop a film, which causes cloudiness comparable to a cataract. Known as posterior capsular opacification (PCO) or secondary cataract, this condition may appear a short time after initial extraction, or may not occur for many years. Treatment with a laser capsulotomy, often called a YAG laser, makes an opening in the cloudy capsule, allowing for clearer vision. Code 66821 (Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages)) when performing a laser capsulotomy.

Successful cataract procedures improve quality of life for many patients. Understanding the nuances and variety of available procedures and options allows for confidence in coding. When following a thorough, detailed op note, coding the correct procedure(s) brings maximum reimbursement and ensures compliance in the event of a review or audit. Though the lens may be cloudy, the coding doesn’t have to be.

Christine Killeen, CPC, CPB, COPC, Contributing Writer