What's important when documenting complex cataract cases?

You're wise to ask about documentation for complex cataract, because it is crucial in these cases. If you don't document CPT Code 66982 adequately, you will not be reimbursed appropriately. Properly coded complex cataract cases are reimbursed at about $176 more than uncomplicated cataract cases.
CPT Code 66982 covers cataract cases for pediatric patients, those with prior eye disease, and cases that require extraordinary techniques and instruments. To qualify the case as complicated, the operative report must clearly document that one or more of these clinical conditions are present.

The following is the actual operative report for a case that is correctly coded. The case involved multiple medical conditions and procedures is properly coded as Diagnosis Codes 366.16 (cataract) and 365.10 (glaucoma) and CPT Codes 66982-RT (right eye complex cataract surgery) and 66180-RT (right eye revision of an aqueous shunt/Aquaflo prosthesis).

I've underlined and placed in bold type the phrases that clearly indicate the complication (pupillary myosis) and the extraordinary instrument (iris retraction devices) and extraordinary technique (continuous-tear capsulotomy). The diagnoses clearly state that the patient suffers from open-angle glaucoma. The details of the report demonstrate that this was a complicated cataract case.

Operative Report
Date of Procedure: 8/12/02
Pre-operative Diagnoses:
 1. Nuclear sclerotic cataract, OD
 2. Pupillary myosis, OD
3. Open-angle glaucoma, OD, uncontrolled on multiple medications and noncompliance
Postoperative Diagnoses:
 1. Nuclear sclerotic cataract, OD
 2. Pupillary myosis, OD
 3. Open-angle glaucoma, OD, uncontrolled on multiple medications and noncompliance
Operative Procedure:
 1. Cataract extraction with posterior chamber intraocular lens, OD; clear cornea phacoemulsification
 2. High risk retraction
 3. Viscocanalostomy with Aquaflo prosthesis
Anethesisa: MAC, peribulbar, O'Brien's
Complications: None
Description of procedure: [A full description of anesthesia and patient prep is given.] A stab incision was made with a 30-degree Superblade, and Viscoat was injected. There was inadequate dilation and consequently three additional paracenteses were created, and iris retraction devices were used for pupillary dilation.

A partial-thickness corneal incision was made at the temporal limbus with a keratome blade, and this blade was used to enter the anterior chamber. An anterior capsulotomy was performed with the cystotome in a continuous-tear circular capsulorhexis fashion. BSS was used to hydrodelineate the lens' nucleus. The lens' nucleus was dispersed with the phacoemulsification unit from Alcon, Model 20000.

Irrigation-aspiration mode was used to remove cortical material. Following cortical cleanup, Provisc was injected, and a posterior chamber intraocular lens from Allergan, model AR40E, 23.0 diopter power, Serial Number 4226730202 was injected in the bag and centered. Miochol was injected for myolysis.

There had been two iris prolapses during the phacoemulsification phase, and a small amount of Provisc was used to keep the iris from the wound. A single 10-0 nylon suture was used to secure the wound, and after reinflating with BSS, the wound was checked and noted to be watertight. Attention was then drawn to the superior limbal area and a microscope was changed.

A conjunctival cutdown incision was made, down to perisclera, and hemostatis was maintained with bipolar cautery. A 5-mm trabeculectomy flap was created with a straight crease upper plate. This trabeculectomy flap was carried up into the clear cornea. A second 4x4 mm dimension trabeculectomy flap was created in a deep scleral fashion. This dissection was carried anteriorly, also into clear cornea, and the roof of Schlemm's canal was visible in the anterior-most aspect.

The secondary flap was excised and Schlemm's canal was unroofed with tube forceps. An Aquaflo device from Starr, Model CGDD-20, Serial Number A1141935 was placed to maintain patency of the trabeculectomy flap. This was then brought forth, and secured in position with two 10-0 nylon sutures. The conjunctival flap was then secured with 7-0 Vicryl tied in interrupted fashion.

[A full description of postop medication and care is given.] 

Ms. Jones, a registered health information officer and certified coding specialist, is the author of the ASC Clinic: Eye and Oculoplastic Surgery coding and billing manual. Contact her at LolitaMJ@aol.com.