Most cataract removals are referred to ECCEs or extracapsular cataract extractions and are performed with the concomitant insertion of an IOL or intraocular lens. When this procedure is performed, the CPT code assigned is 66984. Modifiers should be appended as well to indicate the laterality of the procedure that was performed; RT, LT, or 50. If the same procedure was performed via an intracapsular extraction, the code would be 66983. The difference between extracapsular and intracapsular extraction is that when an extracapsular extraction is performed, only the lens material is removed with the posterior capsule remaining intact; whereas for intracapsular extraction, which is rarely performed, the entire capsule as well as the lens material is removed.
As noted, the codes above will include the IOL insertion performed during the same encounter. If the patient has to have the cataract removed and the IOL inserted at a separate encounter, the coding will change. The appropriate cataract removal code will be found in the CPT range of 66840-66940 and should be assigned based on the method of extraction: aspiration, phacofragmentation, etc. When the patient returns at a subsequent encounter for the IOL insertion, 66985 is the CPT code to assign.
Coding professional should be aware that there are a number of components that may be a part of a cataract surgery which can include lateral canthotomy, iridectomy, iridotomy, anterior capsulotomy, posterior capsulotomy, the use of viscoelastic agents, enzymatic zonulysis, use of other pharmacologic agents, and subconjunctival or sub-Tenon injections. The performance of any of these services is considered part of the overall cataract extraction procedure and should not be separately reported. However, if a vitrectomy is performed at the same time as the cataract extraction, it is not considered part of the bundled services and an additional code for the vitrectomy should be added.
There are some occasions when cataract extractions become more complicated. For example, the patient’s pupil may not dilate well or zonular dehiscence may occur during the procedure. In either circumstance, either before the procedure actually begins or after the IOL has been inserted, if such a condition occurs, the surgeon may place a Malyugin ring or a capsular tension ring, respectively. The use of these devices will impact the CPT code choice, which will change to 66982. This code is to be used when devices are used to expand the iris, sutures are used to support the lens, or in the event that a posterior capsulorrhexis must be performed. The same code should be used if the cataract surgery is performed on a patient in the amblyogenic developmental stage.
Just a quick word on zonular dehiscence or zonular dialysis. This is a condition of the zonules of the eye (zonule of Zinn), which are fibrous bands that connect the lens with the ciliary body (see picture below). This collection of bands, approximately 140, provides support to the lens. If the zonules are damaged or weakened, subluxation of the lens can result.
Postprocedurally, if the intraocular lens becomes subluxated, repositioning may be needed. For those procedures, CPT code 66825 should be assigned.
Coding professionals should take care not to confuse initial cataract extractions with removal of secondary cataracts, which can also be termed after-cataracts or opacified posterior capsules. Procedures for treatment of secondary cataracts depends on the method of removal; either via a stab incision (66820) or YAG laser (66821).
One final tidbit of information. In a 1st Qtr. 2007 Coding Clinic for HCPCS, a question about coding for limbal relaxing incisions performed during cataract surgery was posed. The advice given was that limbal relaxing incisions are incidental to cataract extractions and therefore, not reported separately. This procedure may be performed in patients who present with astigmatism. If the procedure is performed independently, coding professionals are directed to use the unlisted code 66999 for reporting.
Now, light has been shed on coding for cataract extraction procedures.
About the AuthorDianna Foley, RHIA, CHPS, CCS is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant.
She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.