Cataract Surgery and Complex Cataract Surgery (L30159)
Contractor Information
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Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30159 LCD Title Cataract Surgery and Complex Cataract Surgery Contractor's Determination Number OPHTH-020 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 12/16/2009 Original Determination Ending Date Revision Effective Date For services performed on or after 02/21/2011 Revision Ending Date |
CMS National Coverage Policy
Title XVIII of the Social Security Act section 1833 ί (2) (A) The amount of payment to be made for facility services furnished in connection with a surgical procedure specified pursuant to paragraph (1) (A) and furnished to an individual in an ambulatory surgical center
Title XVIII of the Social Security Act, section 1862(a)(7) excludes routine physical examination and screening tests performed in the absence of signs or symptoms from coverage.
Title XVIII of the Social Security Act, section 1862(a)(1)(A) allows coverage and payment for services considered medically reasonable and necessary.
Title XVIII of the Social Security Act, section 1833(e) prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.
Code of Federal Regulations 42 CFR Ch.IV [405.201-405.215] Medical services coverage decisions that relate to health care technology.
Code of Federal Regulations 42 CFR Ch.IV [411.15(o)(1)(2)] Particular services excluded from coverage.
Code of Federal Regulation 42 CFR Ch IV [411.406] Criteria for determining that services were excluded from coverage as not reasonable
Code of Federal Regulation 42 Ch IV [416.65] Covered surgical procedures
Medicare Benefit Policy Manual, Pub.100-2, Chapter 14, §30 for coverage of FDA approved IDEs
Medicare Benefit Policy Manual, Pub.100-2, Chapter 15, §260.5 for a list of covered ambulatory surgical procedures
Medicare National Coverage Determinations, Pub.100-3, Chapter 1, Part 4, §310.1 for routine costs and clinical trials
Medicare Claims Processing Manual, Pub.100-4, Chapter 12, §20.4.6, 20.5 for payment due to unusual circumstances and no adjustments in fee schedule amounts
Medicare Claims Processing Manual, Pub.100-4, Chapter 14, §10.4 for coverage of services in ASCs which are not on the ASC facility code list
Medicare Claims Processing Manual, Pub.100-4, Chapter 14, §20 for a list of covered ASC procedures
Program Memorandum AB-01-81, CR#1670, dated May 15, 2001 for updates of codes and payments for Ambulatory Surgical Centers (ASCs).
Title XVIII of the Social Security Act, section 1862(a)(7) excludes routine physical examination and screening tests performed in the absence of signs or symptoms from coverage.
Title XVIII of the Social Security Act, section 1862(a)(1)(A) allows coverage and payment for services considered medically reasonable and necessary.
Title XVIII of the Social Security Act, section 1833(e) prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.
Code of Federal Regulations 42 CFR Ch.IV [405.201-405.215] Medical services coverage decisions that relate to health care technology.
Code of Federal Regulations 42 CFR Ch.IV [411.15(o)(1)(2)] Particular services excluded from coverage.
Code of Federal Regulation 42 CFR Ch IV [411.406] Criteria for determining that services were excluded from coverage as not reasonable
Code of Federal Regulation 42 Ch IV [416.65] Covered surgical procedures
Medicare Benefit Policy Manual, Pub.100-2, Chapter 14, §30 for coverage of FDA approved IDEs
Medicare Benefit Policy Manual, Pub.100-2, Chapter 15, §260.5 for a list of covered ambulatory surgical procedures
Medicare National Coverage Determinations, Pub.100-3, Chapter 1, Part 4, §310.1 for routine costs and clinical trials
Medicare Claims Processing Manual, Pub.100-4, Chapter 12, §20.4.6, 20.5 for payment due to unusual circumstances and no adjustments in fee schedule amounts
Medicare Claims Processing Manual, Pub.100-4, Chapter 14, §10.4 for coverage of services in ASCs which are not on the ASC facility code list
Medicare Claims Processing Manual, Pub.100-4, Chapter 14, §20 for a list of covered ASC procedures
Program Memorandum AB-01-81, CR#1670, dated May 15, 2001 for updates of codes and payments for Ambulatory Surgical Centers (ASCs).
Indications and Limitations of Coverage and/or Medical Necessity
A cataract is an opacity or cloudiness in the lens of the eye(s), blocking the passage of light through the lens, sometimes resulting in impaired vision. Cataract development occurs in 60% of adults 65 years of age or greater. There are multiple factors associated with cataract development. Some causes of cataracts may include: ultraviolet-β radiation exposure, complications of diabetes, drug and/or alcohol use, smoking, and the natural process of aging. Medicare coverage for cataract extraction and cataract extraction with intraocular lens implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries with cataract(s). This policy defines coverage and describes criteria necessary to justify the performance of cataract extraction(s) or other select lensectomies. Medicare coverage for cataract extraction and cataract extraction with intraocular lens implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries who have a cataract, and who meet all of the following criteria:
The patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented:
- Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; and
- The patient has a best corrected visual acuity of 20/40 or worse at distance or near; or additional testing shows one of the following:
o Consensual light testing decreases visual acuity by two lines, or
o Glare testing decreases visual acuity by two lines
- Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the only cause of decreased visual function; and
- Significant improvement in visual function can be expected as a result of cataract extraction; and
- The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); and
- The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and ophthalmic biometry.
Cataract extraction may be covered when an unimpeded view of the fundus is mandatory for proper management of patients with diseases of the posterior segment of the eye(s).
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.
Bilateral cataract extraction typically should not be performed on the same day because of the potential for bilateral visual loss. If the first cataract extraction is performed and a subsequent contralateral cataract extraction is considered, the criteria for coverage of the procedure in the contralateral are the same as the criteria for the first cataract extraction. Documentation of medical necessity is required if cataract surgery is performed on both eyes on the same day.
Additionally, the restoration of binocular vision, i.e., a clinically significant anisometropia, may also constitute an indication for surgery. If an implant is used in the first eye, often cataract surgery is required in the second eye within weeks to restore binocular function.
Complex Cataract Surgery (CPT Code 66982)
Representatives of the American Academy of Ophthalmology, and the American Society of Cataract and Refractive Surgery estimate that one (1) percent to four (4) percent of cataract operations require the extraordinary work sufficient to meet the definition of complex cataract surgery. Ophthalmologic societies, including the American Society of Cataract and Refractive Surgery, predict these cases will be disproportionately distributed
The code for complex cataract surgery (66982) is intended to differentiate the extraordinary work performed during the intraoperative or postoperative periods in a subset of cataract operations.
Indications and limitations for the use of CPT code 66982.
1. A miotic pupil which will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye and which requires the insertion of iris retractors through additional incisions, mechanical expansion of the pupil, a sector iridectomy with subsequent suture repair of iris sphincter, use of a Malyugian ring and multiple iris sphincterotomies created with scissors. This situation is most commonly encountered in Intraoperative Floppy Iris Syndrome (ICD-9 364.81), as a result of Tamsulosin (Flomax) use or medications with similar side effects.
2. The presence of a disease state that produces lens support structures that are abnormally weak or absent. This requires the need to support the lens implant with permanent intraocular sutures, or when a capsular support ring may be necessary to allow secure placement of an intraocular lens.
3. Pediatric cataract surgery may be more difficult intraoperatively because of an anterior capsule which is more difficult to tear, cortex which is more difficult to remove, and the need for a primary posterior capsulotomy or capsulorhexis. Furthermore, there is additional postoperative work associated with pediatric cataract surgery.
4. Extraordinary work may occur during the postoperative period. This is the case with pediatric cases mentioned above and very rarely when there is extreme postoperative inflammation and pain.
5. Use of intraocular dyes to stain the lens capsule.
The patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented:
- Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; and
- The patient has a best corrected visual acuity of 20/40 or worse at distance or near; or additional testing shows one of the following:
o Consensual light testing decreases visual acuity by two lines, or
o Glare testing decreases visual acuity by two lines
- Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the only cause of decreased visual function; and
- Significant improvement in visual function can be expected as a result of cataract extraction; and
- The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); and
- The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and ophthalmic biometry.
Cataract extraction may be covered when an unimpeded view of the fundus is mandatory for proper management of patients with diseases of the posterior segment of the eye(s).
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.
Bilateral cataract extraction typically should not be performed on the same day because of the potential for bilateral visual loss. If the first cataract extraction is performed and a subsequent contralateral cataract extraction is considered, the criteria for coverage of the procedure in the contralateral are the same as the criteria for the first cataract extraction. Documentation of medical necessity is required if cataract surgery is performed on both eyes on the same day.
Additionally, the restoration of binocular vision, i.e., a clinically significant anisometropia, may also constitute an indication for surgery. If an implant is used in the first eye, often cataract surgery is required in the second eye within weeks to restore binocular function.
Complex Cataract Surgery (CPT Code 66982)
Representatives of the American Academy of Ophthalmology, and the American Society of Cataract and Refractive Surgery estimate that one (1) percent to four (4) percent of cataract operations require the extraordinary work sufficient to meet the definition of complex cataract surgery. Ophthalmologic societies, including the American Society of Cataract and Refractive Surgery, predict these cases will be disproportionately distributed
The code for complex cataract surgery (66982) is intended to differentiate the extraordinary work performed during the intraoperative or postoperative periods in a subset of cataract operations.
Indications and limitations for the use of CPT code 66982.
1. A miotic pupil which will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye and which requires the insertion of iris retractors through additional incisions, mechanical expansion of the pupil, a sector iridectomy with subsequent suture repair of iris sphincter, use of a Malyugian ring and multiple iris sphincterotomies created with scissors. This situation is most commonly encountered in Intraoperative Floppy Iris Syndrome (ICD-9 364.81), as a result of Tamsulosin (Flomax) use or medications with similar side effects.
2. The presence of a disease state that produces lens support structures that are abnormally weak or absent. This requires the need to support the lens implant with permanent intraocular sutures, or when a capsular support ring may be necessary to allow secure placement of an intraocular lens.
3. Pediatric cataract surgery may be more difficult intraoperatively because of an anterior capsule which is more difficult to tear, cortex which is more difficult to remove, and the need for a primary posterior capsulotomy or capsulorhexis. Furthermore, there is additional postoperative work associated with pediatric cataract surgery.
4. Extraordinary work may occur during the postoperative period. This is the case with pediatric cases mentioned above and very rarely when there is extreme postoperative inflammation and pain.
5. Use of intraocular dyes to stain the lens capsule.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 085x | Critical Access Hospital |
Revenue Codes:
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
Revenue codes 096x, 097x and 098x are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or Part B MAC or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI or Part A MAC using revenue code 096x.
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
Revenue codes 096x, 097x and 098x are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or Part B MAC or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI or Part A MAC using revenue code 096x.
| 360X | Operating Room Services - General Classification |
| 370X | Anesthesia - General Classification |
| 490X | Ambulatory Surgical Care - General Classification |
| 710X | Recovery Room - General Classification |
| 760X | Specialty Services - General Classification |
| 960X | Professional Fees - General Classification |
| 66840 | Removal of lens material |
| 66850 | Removal of lens material |
| 66852 | Removal of lens material |
| 66920 | Extraction of lens |
| 66930 | Extraction of lens |
| 66940 | Extraction of lens |
| 66982 | Cataract surgery complex |
| 66983 | Cataract surg w/iol 1 stage |
| 66984 | Cataract surg w/iol 1 stage |
ICD-9 Codes that Support Medical Necessity
(66840, 66850, 66852, 66920, 66930, 66940, 66983, and 66984)
ICD-9 Codes that Support Medical Necessity for CPT code 66982
Note: ICD-9 codes must be coded to the highest level of specificity.
| 361.00 - 361.07 | RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL |
| 361.81 | TRACTION DETACH OF RETINA |
| 362.01 - 362.07 | BACKGROUND DIABETIC RETINOPATHY - DIABETIC MACULAR EDEMA |
| 362.14 | RETINAL MICROANEURYSMS NOS |
| 362.15 | RETINAL TELANGIECTASIA |
| 362.29 | OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY |
| 362.52 | EXUDATIVE SENILE MACULAR DEGENERATION OF RETINA |
| 362.54 | MACULAR CYST HOLE OR PSEUDOHOLE OF RETINA |
| 362.56 | MACULAR PUCKERING OF RETINA |
| 362.83 | RETINAL EDEMA |
| 364.23 | LENS-INDUCED IRIDOCYCLITIS |
| 365.51 | PHACOLYTIC GLAUCOMA |
| 366.00 - 366.09 | NONSENILE CATARACT UNSPECIFIED - OTHER AND COMBINED FORMS OF NONSENILE CATARACT |
| 366.10 - 366.19 | SENILE CATARACT UNSPECIFIED - OTHER AND COMBINED FORMS OF SENILE CATARACT |
| 366.20 - 366.23 | TRAUMATIC CATARACT UNSPECIFIED - PARTIALLY RESOLVED TRAUMATIC CATARACT |
| 366.30 - 366.34 | CATARACTA COMPLICATA UNSPECIFIED - CATARACT IN DEGENERATIVE OCULAR DISORDERS |
| 366.41 - 366.46 | DIABETIC CATARACT - CATARACT ASSOCIATED WITH RADIATION AND OTHER PHYSICAL INFLUENCES |
| 366.8 | OTHER CATARACT |
| 366.9 | UNSPECIFIED CATARACT |
| 367.31 | ANISOMETROPIA |
| 379.23 | VITREOUS HEMORRHAGE |
| 379.32 - 379.34 | SUBLUXATION OF LENS - POSTERIOR DISLOCATION OF LENS |
| 743.35 - 743.39 | CONGENITAL APHAKIA - OTHER CONGENITAL CATARACT AND LENS ANOMALIES |
| 998.82 | CATARACT FRAGMENTS IN EYE FOLLOWING CATARACT SURGERY |
ICD-9 Codes that Support Medical Necessity for CPT code 66982
Note: ICD-9 codes must be coded to the highest level of specificity.
| 364.23 | LENS-INDUCED IRIDOCYCLITIS |
| 364.51 | ESSENTIAL OR PROGRESSIVE IRIS ATROPHY |
| 364.55 | MIOTIC CYSTS OF PUPILLARY MARGIN |
| 364.59 | OTHER IRIS ATROPHY |
| 364.75 | PUPILLARY ABNORMALITIES |
| 364.76 | IRIDODIALYSIS |
| 364.81 | FLOPPY IRIS SYNDROME |
| 364.82 | PLATEAU IRIS SYNDROME |
| 364.9 | UNSPECIFIED DISORDER OF IRIS AND CILIARY BODY |
| 366.00 | NONSENILE CATARACT UNSPECIFIED |
| 366.01 | ANTERIOR SUBCAPSULAR POLAR NONSENILE CATARACT |
| 366.02 | POSTERIOR SUBCAPSULAR POLAR NONSENILE CATARACT |
| 366.03 | CORTICAL LAMELLAR OR ZONULAR NONSENILE CATARACT |
| 366.04 | NUCLEAR NONSENILE CATARACT |
| 366.09 | OTHER AND COMBINED FORMS OF NONSENILE CATARACT |
| 366.10 | SENILE CATARACT UNSPECIFIED |
| 366.11 | PSEUDOEXFOLIATION OF LENS CAPSULE |
| 366.13 | ANTERIOR SUBCAPSULAR POLAR SENILE CATARACT |
| 366.14 | POSTERIOR SUBCAPSULAR POLAR SENILE CATARACT |
| 366.15 | CORTICAL SENILE CATARACT |
| 366.16 | SENILE NUCLEAR SCLEROSIS |
| 366.17 | TOTAL OR MATURE CATARACT |
| 366.18 | HYPERMATURE CATARACT |
| 366.19 | OTHER AND COMBINED FORMS OF SENILE CATARACT |
| 366.20 | TRAUMATIC CATARACT UNSPECIFIED |
| 366.21 | LOCALIZED TRAUMATIC OPACITIES |
| 366.22 | TOTAL TRAUMATIC CATARACT |
| 366.23 | PARTIALLY RESOLVED TRAUMATIC CATARACT |
| 366.30 | CATARACTA COMPLICATA UNSPECIFIED |
| 366.32 | CATARACT IN INFLAMMATORY OCULAR DISORDERS |
| 366.33 | CATARACT WITH OCULAR NEOVASCULARIZATION |
| 366.41 | DIABETIC CATARACT |
| 366.42 | TETANIC CATARACT |
| 366.43 | MYOTONIC CATARACT |
| 366.44 | CATARACT ASSOCIATED WITH OTHER SYNDROMES |
| 366.45 | TOXIC CATARACT |
| 366.46 | CATARACT ASSOCIATED WITH RADIATION AND OTHER PHYSICAL INFLUENCES |
| 379.32 | SUBLUXATION OF LENS |
| 379.33 | ANTERIOR DISLOCATION OF LENS |
| 379.34 | POSTERIOR DISLOCATION OF LENS |
| 379.40 - 379.49 | ABNORMAL PUPILLARY FUNCTION UNSPECIFIED - OTHER ANOMALIES OF PUPILLARY FUNCTION |
| 743.36 | CONGENITAL ANOMALIES OF LENS SHAPE |
| 743.37 | CONGENITAL ECTOPIC LENS |
| 743.45 | ANIRIDIA |
| 743.46 | OTHER SPECIFIED CONGENITAL ANOMALIES OF IRIS AND CILIARY BODY |
Diagnoses that Support Medical Necessity
Diagnoses listed above.
ICD-9 Codes that DO NOT Support Medical Necessity
Any ICD-9-CM code not listed above.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed in section: ICD-9 Codes that Support Medical Necessity
General Information
1. Requirements for diagnoses 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 362.14, 362.15, 362.29, 362.52, 362.54, 362.56 and 362.83;
These codes require coding of the underlying diagnosis.
2. ICD-9 code 998.82 is only allowed for CPT codes 66840, 66850 and 66852.
3. Physicians' Services and diagnostic tests must be submitted with an ICD-9 code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit specificity. This means the precise ICD-9 code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the 4th or 5th digit sub-classification for the diagnosis category. The ICD-9 code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the ICD-9 code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury a screening diagnosis should be reported, and payment will be denied.
4. The patient's medical records should be legible and contain the relevant history and physical findings conforming to the criteria stated in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy and must be made available to the Contractor on request.
Documentation Requirements for Complex Cataract Surgery (CPT Code 66982)
1. Requirement for diagnoses: 364.55, 366.32, 366.33;
Indicate in the operative note micro iris hooks were inserted through corneal incisions, mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter.
2. Requirement for diagnoses: 366.00, 366.01, 366.02, 366.03, 366.04, 366.09, 366.10, 366.11, 366.13, 366.14, 366.16, 366.19, 366.23, 366.41, 366.44, 366.45, 366.46, 743.46;
Indicate in the operative note the use of micro iris hooks inserted through corneal incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring.
3. Requirement for diagnoses: 366.20, 366.21, 366.22;
Indicate in the operative note the use of micro iris hooks inserted through corneal incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular suture or a capsular support ring was employed.
4. Requirement for diagnoses: 364.23, 364.51, 364.59, 364.75;
Indicate in the operative note the use of an endocapsular ring to partially occlude the pupil.
5. Requirement for diagnoses: 379.32, 379.33, 379.34, 743.36, 743.37;
Indicate in the operative note that the intraocular lens was supported by using permanent intraocular sutures or a capsular support ring.
6. Requirement for diagnoses: 364.81, 364.82;
Indicate in the operative note the use of micro iris hooks inserted through cornea incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, permanent intraocular suture or a capsular support ring, or a ring used to partially occlude the pupil.
7. Requirement for diagnoses: 364.9;
Indicate in the operative note that micro iris hooks were inserted through corneal incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, and the intraocular lens was supported by using permanent intraocular suture or a capsular support ring was employed to partially occlude the pupil.
8. Requirement for diagnoses: 364.76;
Indicate in the operative note that a capsular support ring was employed to partially occlude the pupil.
9. Requirement for diagnoses: 366.17;
Indicate in the operative note that dye was used to stain the anterior capsule.
10. Requirement for diagnoses: 366.30;
Indicate in the operative note the use of micro iris hooks inserted through corneal incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, intraocular lens implant was supported by using permanent interocular sutures, a capsular support ring was employed or a primary posterior capsulorhexis was performed.
11. Requirement for diagnoses: 366.42, 366.43;
Indicate in the operative note or postoperative records that an extraordinary amount of work was involved in the preoperative or postoperative care.
12. Requirement for diagnoses: 379.40-379.49;
Indicate in the operative note the use of micro iris hooks inserted through incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.
13. Requirement for diagnoses: 743.45;
Indicate in the operative note that the intraocular lens was supported in the eye by using permanent intraocular sutures, and a capsular support ring was employed to partially occlude the pupil.
Appendices
These codes require coding of the underlying diagnosis.
2. ICD-9 code 998.82 is only allowed for CPT codes 66840, 66850 and 66852.
3. Physicians' Services and diagnostic tests must be submitted with an ICD-9 code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit specificity. This means the precise ICD-9 code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the 4th or 5th digit sub-classification for the diagnosis category. The ICD-9 code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the ICD-9 code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury a screening diagnosis should be reported, and payment will be denied.
4. The patient's medical records should be legible and contain the relevant history and physical findings conforming to the criteria stated in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy and must be made available to the Contractor on request.
Documentation Requirements for Complex Cataract Surgery (CPT Code 66982)
1. Requirement for diagnoses: 364.55, 366.32, 366.33;
Indicate in the operative note micro iris hooks were inserted through corneal incisions, mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter.
2. Requirement for diagnoses: 366.00, 366.01, 366.02, 366.03, 366.04, 366.09, 366.10, 366.11, 366.13, 366.14, 366.16, 366.19, 366.23, 366.41, 366.44, 366.45, 366.46, 743.46;
Indicate in the operative note the use of micro iris hooks inserted through corneal incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring.
3. Requirement for diagnoses: 366.20, 366.21, 366.22;
Indicate in the operative note the use of micro iris hooks inserted through corneal incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular suture or a capsular support ring was employed.
4. Requirement for diagnoses: 364.23, 364.51, 364.59, 364.75;
Indicate in the operative note the use of an endocapsular ring to partially occlude the pupil.
5. Requirement for diagnoses: 379.32, 379.33, 379.34, 743.36, 743.37;
Indicate in the operative note that the intraocular lens was supported by using permanent intraocular sutures or a capsular support ring.
6. Requirement for diagnoses: 364.81, 364.82;
Indicate in the operative note the use of micro iris hooks inserted through cornea incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, permanent intraocular suture or a capsular support ring, or a ring used to partially occlude the pupil.
7. Requirement for diagnoses: 364.9;
Indicate in the operative note that micro iris hooks were inserted through corneal incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, and the intraocular lens was supported by using permanent intraocular suture or a capsular support ring was employed to partially occlude the pupil.
8. Requirement for diagnoses: 364.76;
Indicate in the operative note that a capsular support ring was employed to partially occlude the pupil.
9. Requirement for diagnoses: 366.17;
Indicate in the operative note that dye was used to stain the anterior capsule.
10. Requirement for diagnoses: 366.30;
Indicate in the operative note the use of micro iris hooks inserted through corneal incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, intraocular lens implant was supported by using permanent interocular sutures, a capsular support ring was employed or a primary posterior capsulorhexis was performed.
11. Requirement for diagnoses: 366.42, 366.43;
Indicate in the operative note or postoperative records that an extraordinary amount of work was involved in the preoperative or postoperative care.
12. Requirement for diagnoses: 379.40-379.49;
Indicate in the operative note the use of micro iris hooks inserted through incisions, a mechanical iris expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.
13. Requirement for diagnoses: 743.45;
Indicate in the operative note that the intraocular lens was supported in the eye by using permanent intraocular sutures, and a capsular support ring was employed to partially occlude the pupil.
See section titled Indications and Limitations and section titled Documentation Requirements.
Sources of Information and Basis for Decision
1. American Academy of Ophthalmology (1996), Preferred Practice Pattern, Cataract in the Adult Eyes
2. American Academy of Ophthalmology (1999, December 9), Washington Report
3. American Medical Association; CPT Editorial Panel; November 4 and 6, 1999.
4. Belcher M 2000 year in review cataract/IOL Review of Ophthalmology 2000; Nov. 54-74
5. Chitkara D., Smerdon D., (1997) Risk factors complications and results in extracapsular cataract surgery. J Cataract Refract Surgery; 23: 570-573
6. Cumming R., Mitchell P. and Smith W., (2000) Diet and cataract, the Blue Mountain eye study. Ophthalmology, 107: 450-456
7. Fine I., Hoffman R., (1997) Phacoemulsefication in the presence of pseudoexfoliation: challenges and
Options. J Cataract and Refractive Surgery; 23: 160-164
8. Guzek J., Holm M., Cotter J., et.al. (1987) Risk factors for intraoperative complications in 1000
extracapsular cataract cases. Ophthalmology; 94: 461-466
9. Klein B., Klein R, Linton K., (1992) Prevalence of age-related lens opacities in a population. the
Beaver Dam eye study. Ophthalmology; 92: 546-552
10. Ronge LJ, Clinical Update: How endo rings can help you Eye Net 2000; 4: 25-26
11. Schumacher S., Nguyen N., Kuchle M., and Naumann G., (1999) Quantification of aqueous flare after phacoemulsification with intraocular lens implantation in eyes with pseudoexfoliation syndrome. Arch Opthal; 117: 733-735
12. Scorolli L., Campos E., Bassein L. and Meduri R. (1998) Pseudoexfoliation syndrome: A cohort
study on intraoperative complications in cataract surgery, Ophthalmologic; 212:278-280
13. Sommer A. Tielsch JM, Katz J, et.al (1991) Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med; 325: 1412-1417
Advisory Committee Meeting Notes
2. American Academy of Ophthalmology (1999, December 9), Washington Report
3. American Medical Association; CPT Editorial Panel; November 4 and 6, 1999.
4. Belcher M 2000 year in review cataract/IOL Review of Ophthalmology 2000; Nov. 54-74
5. Chitkara D., Smerdon D., (1997) Risk factors complications and results in extracapsular cataract surgery. J Cataract Refract Surgery; 23: 570-573
6. Cumming R., Mitchell P. and Smith W., (2000) Diet and cataract, the Blue Mountain eye study. Ophthalmology, 107: 450-456
7. Fine I., Hoffman R., (1997) Phacoemulsefication in the presence of pseudoexfoliation: challenges and
Options. J Cataract and Refractive Surgery; 23: 160-164
8. Guzek J., Holm M., Cotter J., et.al. (1987) Risk factors for intraoperative complications in 1000
extracapsular cataract cases. Ophthalmology; 94: 461-466
9. Klein B., Klein R, Linton K., (1992) Prevalence of age-related lens opacities in a population. the
Beaver Dam eye study. Ophthalmology; 92: 546-552
10. Ronge LJ, Clinical Update: How endo rings can help you Eye Net 2000; 4: 25-26
11. Schumacher S., Nguyen N., Kuchle M., and Naumann G., (1999) Quantification of aqueous flare after phacoemulsification with intraocular lens implantation in eyes with pseudoexfoliation syndrome. Arch Opthal; 117: 733-735
12. Scorolli L., Campos E., Bassein L. and Meduri R. (1998) Pseudoexfoliation syndrome: A cohort
study on intraoperative complications in cataract surgery, Ophthalmologic; 212:278-280
13. Sommer A. Tielsch JM, Katz J, et.al (1991) Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med; 325: 1412-1417
Meeting Date:
Wisconsin 05/15/2009
Illinois 05/13/2009
Michigan 05/06/2009
Minnesota 05/21/2009
Iowa, Kansas, Missouri, Nebraska 06/04/2009
Start Date of Comment Period
Wisconsin 05/15/2009
Illinois 05/13/2009
Michigan 05/06/2009
Minnesota 05/21/2009
Iowa, Kansas, Missouri, Nebraska 06/04/2009
06/04/2009
End Date of Comment Period
07/20/2009
Start Date of Notice Period
11/01/2009
Revision History Number
An asterisk (*) indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the Contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee, which includes representatives from Ophthalmology.
6/29/09 Removed contractor number 05392 because as of 8/1/09 E MO will join with the current number for W MO
05/17/2009 applied to all contractor numbers
04/03/2009 Approved
04/03/2009 Entered as draft
8/10/2009 - The description for Revenue code 0760 was changed
8/10/2009 - The description for Revenue code 0761 was changed
8/10/2009 - The description for Revenue code 0762 was changed
8/10/2009 - The description for Revenue code 0769 was changed
11/15/2009 - The description for CPT/HCPCS code 66982 was changed in group 1
04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0360 was changed
8/1/2010 - The description for Revenue code 0361 was changed
8/1/2010 - The description for Revenue code 0362 was changed
8/1/2010 - The description for Revenue code 0367 was changed
8/1/2010 - The description for Revenue code 0369 was changed
8/1/2010 - The description for Revenue code 0370 was changed
8/1/2010 - The description for Revenue code 0371 was changed
8/1/2010 - The description for Revenue code 0372 was changed
8/1/2010 - The description for Revenue code 0374 was changed
8/1/2010 - The description for Revenue code 0379 was changed
8/1/2010 - The description for Revenue code 0490 was changed
8/1/2010 - The description for Revenue code 0499 was changed
8/1/2010 - The description for Revenue code 0710 was changed
8/1/2010 - The description for Revenue code 0760 was changed
8/1/2010 - The description for Revenue code 0761 was changed
8/1/2010 - The description for Revenue code 0762 was changed
8/1/2010 - The description for Revenue code 0769 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0961 was changed
8/1/2010 - The description for Revenue code 0962 was changed
8/1/2010 - The description for Revenue code 0963 was changed
8/1/2010 - The description for Revenue code 0964 was changed
8/1/2010 - The description for Revenue code 0969 was changed
8/1/2010 - Revenue code 0719 was deleted
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
66982 descriptor was changed in Group 1
66983 descriptor was changed in Group 1
66984 descriptor was changed in Group 1
02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
04/01/2011: Reformatted and annual review. No coverage changes
Reason for Change
This policy does not reflect the sole opinion of the Contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee, which includes representatives from Ophthalmology.
6/29/09 Removed contractor number 05392 because as of 8/1/09 E MO will join with the current number for W MO
05/17/2009 applied to all contractor numbers
04/03/2009 Approved
04/03/2009 Entered as draft
8/10/2009 - The description for Revenue code 0760 was changed
8/10/2009 - The description for Revenue code 0761 was changed
8/10/2009 - The description for Revenue code 0762 was changed
8/10/2009 - The description for Revenue code 0769 was changed
11/15/2009 - The description for CPT/HCPCS code 66982 was changed in group 1
04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0360 was changed
8/1/2010 - The description for Revenue code 0361 was changed
8/1/2010 - The description for Revenue code 0362 was changed
8/1/2010 - The description for Revenue code 0367 was changed
8/1/2010 - The description for Revenue code 0369 was changed
8/1/2010 - The description for Revenue code 0370 was changed
8/1/2010 - The description for Revenue code 0371 was changed
8/1/2010 - The description for Revenue code 0372 was changed
8/1/2010 - The description for Revenue code 0374 was changed
8/1/2010 - The description for Revenue code 0379 was changed
8/1/2010 - The description for Revenue code 0490 was changed
8/1/2010 - The description for Revenue code 0499 was changed
8/1/2010 - The description for Revenue code 0710 was changed
8/1/2010 - The description for Revenue code 0760 was changed
8/1/2010 - The description for Revenue code 0761 was changed
8/1/2010 - The description for Revenue code 0762 was changed
8/1/2010 - The description for Revenue code 0769 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0961 was changed
8/1/2010 - The description for Revenue code 0962 was changed
8/1/2010 - The description for Revenue code 0963 was changed
8/1/2010 - The description for Revenue code 0964 was changed
8/1/2010 - The description for Revenue code 0969 was changed
8/1/2010 - Revenue code 0719 was deleted
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
66982 descriptor was changed in Group 1
66983 descriptor was changed in Group 1
66984 descriptor was changed in Group 1
02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
04/01/2011: Reformatted and annual review. No coverage changes
04/01/2011
Related Documents
This LCD has no Related Documents.
LCD Attachments
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Page Last Updated: Wednesday, 05-Oct-2011 11:26:17 CDT
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