2020 Updates for Cataract Extraction Procedures

Past “Spotlight on CPT” presented information regarding the correct coding for cataract extractions.  With the January 1^st updates to CPT, there are some revisions and additions that coding professionals should be aware of.  Let’s dive in.

Two existing cataract removal codes 66982 and 66984 have both undergone revision.  For both codes the change is the same and that is the addition of the phrase: without endoscopic cyclophotocoagulation.  Therefore, the first thing we need to know is what is endoscopic cyclophotocoaguation.  It is a laser procedure that is performed (after a cataract extraction) on the ciliary body in order to control glaucoma.  Here is a link to a very short animation of the procedure: https://www.tysoneye.com/glaucoma-cape-coral/endoscopic-cyclophotocoagulation/

Before we move on, just a little detail on the ciliary body.  As an extension of the iris, the ciliary body is a circular structure and has three main functions.  The first is that it helps the eye maintain focus, also known as accommodation.  Next, it is a support for the zonules, which anchor the lens.  Finally, it produces and reabsorbs aqueous humor.  If too much aqueous humor is produced, it raises the intraocular pressure and can result in glaucoma.

Here is a visual to help identify the location of the ciliary body:

Source: https://www.charllaas.com/the-eye/

Here are the revised cataract extraction codes:

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

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

As you might imagine, if we have the option to assign a code without the cyclophotocoagulation, then we probably have a code(s) that support with cyclophotocoagulation.  That’s precisely what we find with the following new CPT codes.

66987 – (sequenced after complex description code 66982) with endoscopic cyclophotocoagulation

66988 – (sequenced after normal description code 66984) with endoscopic cyclophotocoagulation

Now, light has been shed on updates to cataract extractions for 2020.


About the Author 

Dianna 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.

Initial, Subsequent, and Sequela 7th Character Assignment for Injuries, Poisonings, and Fractures

Explore the distinction between initial, subsequent, and sequela 7th character assignment for injuries, poisonings, and fractures in this episode of “In the kNOW.”  The usage of these 7th characters is intended to illustrate the care received for a particular patient encounter.  Let’s look at the meaning of each of these terms to help develop a better understanding of their application.

The 7th character used for initial care is “A” for active care which is explained as:

• Emergency room care 
• Surgical care  
• Evaluation/treatment by same/different physician

It is important to remember that not all surgical care will be active treatment however.  Consider a patient who had a Colles fracture with ORIF and now has a nonunion.  The internal fixation device must be removed so that is a procedure that will be performed after the patient had the active (initial) surgery for the repair and will not carry the “A” designation.  

Additionally, not every physician visit will be active care, even it is the first time a physician sees a patient.  For example, a boy had an ankle fracture and received surgical treatment.  Now, his family has moved to a new city and he has to see a new orthopedist in follow-up. That visit will be of a subsequent nature and carry the appropriate 7th character to reflect that status.

Active care may also be staged or necessitate multiple visits/physicians.

“D” is the 7th character used to show subsequent care for routine healing and recovery.  This can be used in a variety of circumstances such as:

• X-rays to monitor fracture healing
• Cast change/removal
• Internal/external fixation device removal
• Adjustment of medication
• Other types of aftercare or follow up visits

The 7th character for sequela is “S”.  A sequela is a condition/complication that is a direct result of another condition.  Think scar as a result of a burn.  The scar is the sequela.  An important note for sequelae is that there is no time table for a sequela.  It can be evident immediately after an injury or condition like dysphagia following a stroke, or it can take years to manifest such as the development of pleural calcifications years after TB.

The number of 7th characters expands when we talk about fractures.  Here the 7th character will tell if the fracture is:

• Closed/open  (A, B)
• Routine/delayed healing  (D, G)
• Nonunion/malunion  (K, P)
• Sequela  (S)

We’ll find another layer of specificity for those fractures that are designated with the Gustilo classification; open fractures of the forearm, femur, and lower leg.  These 7th characters take into consideration which type of Gustilo classification fits the fracture as outlined below:

• B=initial, open, type I or II
• C=initial open, type IIIA, IIIB, or IIIC
• E=subsequent, open, type I or II routine healing
• F=subsequent, open, type IIIA, IIIB, or IIIC routine healing
• H=subsequent, open, type I or II delayed healing
• J=subsequent, open, type IIIA,IIIB, or IIIC delayed healing
• M=subsequent, open, type I or II nonunion
• N=subsequent, open, type IIIA, IIIB, or IIIC nonunion
• Q=subsequent, open, type I or II malunion
• R=subsequent, open, type IIIA, IIIB, or IIIC malunion

With one exception, aftercare codes should not be assigned when coding care related to injuries, poisonings, and fractures because the 7th characters that have been discussed above provide a more specific indication of the type of aftercare given.  The exception is when a joint prosthesis has been previously removed due to a complication and now, at the episode of care when the replacement prosthesis will be inserted, an aftercare code is appropriate (Z47.3X)-aftercare following explantation of joint prosthesis (staged procedure).   

A final thought, for complications, active treatment relates to the treatment directed to the condition described by the code, not the problem that caused the condition which may have occurred earlier.  For instance, if a patient had a hip fracture and had to have a joint prosthesis which became infected, the code would be for the complication of the joint prosthesis which is infected, not the hip fracture which no longer exists but caused the need for the joint prosthesis. 

Now you are In the kNOW!!

About the Author 

Dianna 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.

Epidural Steroid Injection (ESI) Codes

This installment of “In the kNOW” focuses on the changes to epidural steroid injection (ESI) codes.  Previous codes that identified ESIs have been deleted (62310, 62311, 62318, and 62319) and have been replaced with new codes ranging from 62320-62327. 

ESIs are a common, minimally invasive, treatment method for addressing pain that is the result of inflammation of spinal nerves.  Causes of the pain can be the herniation of an intervertebral disc, spinal stenosis or spondylolysis.  Two medications work in tandem when an ESI is administered.  The first component is a local anesthetic which will work to provide immediate symptom (pain) relief while the second is a corticosteroid which works to reduce the inflammation over time thus affording longer pain relief.  

Until the 2017 CPT update, ESI coding was based on:

the injection site: cervical/thoracic or lumbar/sacral,
            and
the method of administration: injection or injection with indwelling catheter.   

The new 2017 CPT codes for ESIs now include whether or not the ESI was administered with imaging guidance.
–    62320 injection C or T without Imaging Guidance
–    62321 injection C or T with Imaging Guidance
–    62322 injection L or S without Imaging Guidance
–    62323 injection L or S with Imaging Guidance
–    62324 injection with catheter C or T without Imaging Guidance
–    62325 injection with catheter C or T with Imaging Guidance
–    62326 injection with catheter L or S without Imaging Guidance
–    62327 injection with catheter L or S with Imaging Guidance

As coders begin the process of coding for ESIs now, the first consideration will be to determine where the needle or catheter enters the body.  Coders should note that the threading of the catheter into the epidural space, the injection of one or more levels, and the subsequent catheter removal are all components of a single injection.  The ESI should be considered a single injection even if the administered agent spreads to another level or the catheter tip moves into another region.  

When a catheter is placed for an ESI and is used on a single calendar day, coders should report ONE injection only, even if more than one injection is given.  Catheters that are left in place for more than one day in order to provide a bolus or continuous treatment will be coded to the new codes 62324-62327.

Now you are In the kNOW!!

About the Author 

Dianna 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.