Billing and Coding Guideline CPT CODE 66840 – 66984


Cataract removal codes are mutually exclusive of each other and can only be billed once for the same eye. Because CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another, providers may not report multiple codes for the same eye even if more than one technique is used or more than one code could be applicable. Only one code from this CPT code range may be reported for an eye. 

Example 1: For Date of Service (DOS) 10/20/09 the provider billed and received reimbursement for code 66852 LT modifier and also 66984 LT modifier. Since these codes are mutually exclusive of one another only one code should have been reimbursed. Per the NCCI Policy Manual CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye. Therefore Medicare recovered payment for CPT code 66984.



Example 2: For DOS 11/23/10 the provider billed and received reimbursement for 2 units of code 66984 RT modifier. Since cataract removal can only occur once per eye for the same date of service this would be an overpayment. Medicare would adjust the units down to 1 unit for this claim line.





For example, if the surgeon performing a cataract extraction (CPT code 66984) also provides anesthesia (CPT code 00142), the anesthesia service is not reported separately. Therefore, CPT code 00142 is bundled into CPT code 66984.





Example 3: Separate Injury A patient undergoes pterygium surgery in the right eye. During the 90-day global period, she is hit in the left eye with a bungee cord, causing a traumatic cataract and vitreous hemorrhage. Immediate surgery is scheduled. Correct coding for the exam. The appropriate level of E&M (9921X–57) or Eye code (9201X–57). Use of modifier. Modifier –57 indicates that this is the exam to determine the need for surgery. Correct coding for the surgery. CPT code 67036–79–LT (for the vitrectomy) and CPT code 66984–59–79–LT (for the cataract removal). Use of modifiers. NCCI edits bundle 66984 with 67036. When you know preoperatively that both procedures will be performed, it is appropriate to unbundle by appending modifier –59 to 66984. Modifier –79 is used to indicate that these surgeries are unrelated to the pterygium surgery. Know which code to list first. The rules for the reimbursement of multiple procedures mean payment for the code that is listed first will be 100 percent of its allowable; for the code listed second, 50 percent of its allowable. Therefore, the code with the highest allowable—in this case, vitrectomy— should be listed first. 


If Modifier 50 has been used then Medicare would pay 150% of allowed amount.




• UnitedHealthcare will cover the cataract surgery (including the cost of the conventional lens) and the patient is responsible for the cost of the  resbyopiacorrecting IOL to the extent it exceeds the cost of the conventional lens.


The proper facility coding of this procedure is as follows:


Cataract surgery: 66982 or 66984
Covered IOL: V2630-V2632
Non-covered IOL: V2797



Physicians would use CPT codes 66982 or 66984 to receive payment for cataract surgery




CATARACT CO-MANAGEMENT BILLING FOR MEDICARE


Essential elements of the transfer agreement from the optometrist should include the following:


1. Patient Name


2. Operative Eye


3. Nature of Operation


4. Transfer Date


5. Results of First Post-Operative Visit



Both doctors should retain copies of this documentation as part of the patients permanent records. They may also serve as a useful attachment on claims, as necessary.





In cataract surgery procedures (CPT codes 66984 and 66982), an IOL is implanted to replace the natural lens. A conventional IOL is focused to correct the patient’s distance vision but not other refractive errors such as astigmatism. A toric IOL replaces the natural lens and corrects astigmatism as well as distance vision, resulting in patients’ decreased postoperative  dependence on glasses or contact lenses. Medicare and most other insurance carriers specifically exclude coverage for the surgical correction of refractive errors, including astigmatism.


Use of modifiers. NCCI edits bundle


66984 with 67036. When you know preoperatively that both procedures will be performed, it is appropriate to unbundle by appending modifier –59 to 66984. Modifier –79 is used to indicate that these surgeries are unrelated to the pterygium  surgery.


Know which code to list first. The rules for the reimbursement of multiple procedures mean payment for the code that is listed first will be 100 percent of its allowable; for the code listed second, 50 percent of its allowable.



Therefore, the code with the highest allowable—in this case, vitrectomy— should be listed first.


MODIFIERS FOR CLAIMS SUBMISSION


Immediately following surgery, the surgeon can submit a claim for the surgical component of care using the appropriate CPT Code, i.e. 66984, and Modifier 54. This modifier is used to indicate the surgical event in a co-managed case. Medicare assigns 80% of the global fee to the intraoperative service. Later the surgeon will submit a claim for his/her portion of post-operative care. In order for this claim to be accurate, the surgeon needs to know the date the optometrist assumed responsibility for the remaining post-operative care (the transfer date noted above). This claim will be filed using the appropriate CPT Code, i.e. 66984, and Modifier 55, which indicates post-operative management only. After the optometrist has seen the patient for post-operative care, he/she will submit a claim for the postoperative care provided, using the appropriate CPT Code, i.e, 66984, and Modifier 55. Again, in order for the claim to be accurate the optometrist must know the date he/she assumed responsibility for postoperative care (the transfer date). 



Medicare uses chronology and number of days to calculate payment for care rendered by each doctor during the post-operative period (90 days). The fees submitted by the surgeon and optometrist will be different, depending on the number of days of post-operative care each one provided.


Co-Management Modifiers


When more than one physician furnishes services that are part of a global surgery fee package, the following modifiers are
required to identify services furnished by each provider of care:


o Modifier -54 – Surgical Care Only


o Modifier -55- Post-operative Care


Basic coverage requirement for the co-management of a patient is that the surgeon MUST initiate the notification to Medicare
by using modifier -54 with the claim for surgery, e.g., 66984-54. 


o The date of service should be the date of the surgical procedure. 



o The provider who provides the post-operative care bills the same CPT® code as the surgeon with modifier -55, e.g., 66984-55. 




Billing Guidelines


“Co-management” of Postoperative Care for Cataract Surgery (CPT 66984)


Providers should follow CMS billing guidelines. Following are the current billing guidelines as published by National Government Services relative to practitioners who share postoperative management with another practitioner following cataract surgery, CPT 66984.


The Alliance has noticed inconsistencies in billing for these services, therefore, these guidelines are offered to ensure appropriate reimbursement.




Modifier 55 – Postoperative Management Only:


If the practitioner who performs surgery relinquishes care after the surgery, he/she need only show the date of surgery and bill the surgical code(s) with modifier 54-Surgical Care Only (e.g. CPT 66984-54).


If the practitioner continues to care for the patient for some period following the surgery, he/she should bill the date of surgery, the surgical procedure with modifier 54 (indicating surgery only) and a separate line item with the date of surgery, surgical procedure code with modifier 55 (indicating postoperative care). In this case, it would be necessary to show the dates during the postoperative period for which he/she was responsible in Item 19 of the CMS-1500 Form. The “units” field (Item 24g of the CMS-1500 Form) should indicate the exact number of postoperative days the practitioner was responsible for care.


When a transfer of postoperative care occurs, the receiving practitioner may not bill for any part of the global service until he/she has provided at least one service. Once the practitioner has seen the patient, that practitioner may bill for the period beginning with the date on which he assumes care of the patient. The exact number of postoperative days should be given as “units” in Item 24g of the CMS-1500 Form or electronic equivalent. In this case, it would be necessary to show the dates during the postoperative period for which he/she was responsible in Item 19 of the CMS-1500 Form. The date of service should be indicated as the date of surgery. Allowance of the postoperative care for each practitioner will be according to the number of days each practitioner was responsible for the patient’s postoperative care.  2 Example of Billing co-management of postoperative car .






Payment for Services and Supplies


For an IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the hospital Outpatient Prospective Payment System (OPPS) or the Inpatient Prospective Payment System (IPPS), respectively; or in a Medicare-approved ambulatory surgical center (ASC) that is paid under the ASC fee schedule:


• Medicare does not make separate payment to the hospital or ASC for an IOL inserted subsequent to extraction of a cataract. Payment for the IOL is packaged into the payment for the surgical cataract extraction/lens replacement procedure.


• Any person or ASC, who presents or causes to be presented a bill or request for payment for an IOL inserted during or subsequent to cataract surgery for which payment is made under the ASC fee schedule, is subject to a civil money penalty.


• For a P-C IOL or A-C IOL inserted subsequent to removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the OPPS or the IPPS, respectively; or in a Medicare-approved ASC that is paid under the ASC fee schedule:


• The facility shall bill for the removal of a cataract with insertion of a conventional IOL, regardless of whether a conventional, P-C IOL, or A-C IOL is inserted. When a beneficiary receives a P-C or A-C IOL following removal of a cataract, hospitals and ASCs shall report the same Procedure  code that is used to report removal of a cataract with insertion of a conventional IOL. Physicians, hospitals and ASCs may also report an additional HCPCS code, V2788, to indicate any additional charges that accrue when a P-C IOL or A-C IOL is inserted in lieu of a conventional IOL until January 1, 2008. Effective for A-C IOL insertion services on or after January 1, 2008, physicians, hospitals and ASCs should use V2787 to report any additional charges that accrue. On or after January 1, 2008, physicians, hospitals, and ASCs should continue to report HCPCS code V2788 to indicate any additional charges that accrue for insertion of a P-C IOL. See Section 120.2 for coding guidelines.


• There is no Medicare benefit category that allows payment of facility charges for services and supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the facility charges for services and supplies required for the insertion and adjustment of a conventional IOL.


• There is no Medicare benefit category that allows payment of facility charges for subsequent treatments, services and supplies required to examine and monitor the beneficiary who receives a P-C or A-C IOL following removal of a cataract that exceeds the facility charges for subsequent treatments, services and supplies required to examine and monitor a beneficiary after cataract surgery followed by insertion of a conventional IOL.




A – For a P-C IOL or A-C IOL inserted in a physician’s office


– A physician shall bill for a conventional IOL, regardless of a whether a conventional, P-C IOL, or A-C IOL is inserted (see section 120.2, General Billing Requirements)


– There is no Medicare benefit category that allows payment of physician charges for services and supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the physician charges for services and supplies for the insertion and adjustment of a conventional IOL.


– There is no Medicare benefit category that allows payment of physician charges for subsequent treatments, service and supplies required to examine and monitor a beneficiary following removal of a cataract with insertion of a P-C or A-C IOL that exceed physician charges for services and supplies to examine and monitor a beneficiary following removal of a cataract with insertion of a conventional IOL.


B – For a P-C IOL or A-C IOL inserted in a hospital


– A physician may not bill Medicare for a P-C or A-C IOL inserted during a cataract procedure performed in a hospital setting because the payment for the lens is included in the payment made to the facility for the surgical procedure.



– There is no Medicare benefit category that allows payment of physician charges for services and supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the physician charges for services and supplies required for the insertion of a conventional IOL.


ICD-10 CODE DESCRIPTION


E08.36 Diabetes mellitus due to underlying condition with diabetic cataract


E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract


E10.36 Type 1 diabetes mellitus with diabetic cataract


E11.36 Type 2 diabetes mellitus with diabetic cataract


E13.36 Other specified diabetes mellitus with diabetic cataract


H20.21 – H20.23 – Opens in a new window Lens-induced iridocyclitis, right eye – Lens-induced iridocyclitis, bilateral


H25.011 – H25.013 – Opens in a new window Cortical age-related cataract, right eye – Cortical age-related cataract, 
bilateral


H25.031 – H25.033 – Opens in a new window Anterior subcapsular polar age-related cataract, right eye – Anterior 
subcapsular polar age-related cataract, bilateral


H25.041 – H25.043 – Opens in a new window Posterior subcapsular polar age-related cataract, right eye – Posterior 
subcapsular polar age-related cataract, bilateral


H25.091 – H25.093 – Opens in a new window Other age-related incipient cataract, right eye – Other age-related incipient 
cataract, bilateral


H25.11 – H25.13 – Opens in a new window Age-related nuclear cataract, right eye – Age-related nuclear cataract, bilateral


H25.21 – H25.813 – Opens in a new window Age-related cataract, morgagnian type, right eye – Combined forms of age-
related cataract, bilateral


H25.89 Other age-related cataract


H26.001 – H26.003 – Opens in a new window Unspecified infantile and juvenile cataract, right eye – Unspecified 
infantile and juvenile cataract, bilateral


H26.011 – H26.013 – Opens in a new window Infantile and juvenile cortical, lamellar, or zonular cataract, right eye – 
Infantile and juvenile cortical, lamellar, or zonular cataract, bilateral


H26.031 – H26.033 – Opens in a new window Infantile and juvenile nuclear cataract, right eye – Infantile and juvenile 
nuclear cataract, bilateral


H26.041 – H26.043 – Opens in a new window Anterior subcapsular polar infantile and juvenile cataract, right eye – 
Anterior subcapsular polar infantile and juvenile cataract, bilateral


H26.051 – H26.053 – Opens in a new window Posterior subcapsular polar infantile and juvenile cataract, right eye – 
Posterior subcapsular polar infantile and juvenile cataract, bilateral


H26.061 – H26.063 – Opens in a new window Combined forms of infantile and juvenile cataract, right eye – Combined forms 
of infantile and juvenile cataract, bilateral


H26.09 – H26.103 – Opens in a new window Other infantile and juvenile cataract – Unspecified traumatic cataract, 
bilateral


H26.111 – H26.113 – Opens in a new window Localized traumatic opacities, right eye – Localized traumatic opacities, 
bilateral


H26.121 – H26.123 – Opens in a new window Partially resolved traumatic cataract, right eye – Partially resolved 
traumatic cataract, bilateral


H26.131 – H26.133 – Opens in a new window Total traumatic cataract, right eye – Total traumatic cataract, bilateral


H26.20 – H26.213 – Opens in a new window Unspecified complicated cataract – Cataract with neovascularization, 
bilateral


H26.221 – H26.223 – Opens in a new window Cataract secondary to ocular disorders (degenerative) (inflammatory), right 
eye – Cataract secondary to ocular disorders (degenerative) (inflammatory), bilateral


H26.231 – H26.233 – Opens in a new window Glaucomatous flecks (subcapsular), right eye – Glaucomatous flecks 
(subcapsular), bilateral


H26.31 – H26.413 – Opens in a new window Drug-induced cataract, right eye – Soemmering’s ring, bilateral


H26.491 – H26.493 – Opens in a new window Other secondary cataract, right eye – Other secondary cataract, bilateral


H26.8 Other specified cataract


H28 Cataract in diseases classified elsewhere


H40.89 Other specified glaucoma


H52.31 Anisometropia


H59.021 – H59.023 – Opens in a new window Cataract (lens) fragments in eye following cataract surgery, right eye – 
Cataract (lens) fragments in eye following cataract surgery, bilateral


Q12.0 – Q12.2 – Opens in a new window Congenital cataract – Coloboma of lens


Q12.4 – Q12.9 – Opens in a new window Spherophakia – Congenital lens malformation, unspecified

ICD-9-CM Codes That Support Medical Necessity