The biggest challenge to doing complex cataract billing is that your coders won't get much practice at it. The complex cataract CPT code (66982) that CMS added to the ASC list in 2001 only applies to about 1 to 4 percent of cataract cases. While the physician reimbursement for these cases is higher, the unadjusted facility fee of $989 ($839 $150 for the IOL) is the same as for a routine case. The good news is that complex cataract cases need not be money losers. Here are four keys to making sure that you get reimbursed in full - on time, every time.

Know when you can use CPT 66982
You can't bill a case as a complex cataract due to intraoperative complications. To qualify as a complex case, the ophthalmologist must treat an eye with a concurrent disease or congenital pathology, or one that's been subject to prior trauma. Such cases often require specialized instruments or materials not used in routine cases.

Let's look at the official definition of the complex cataract code in the AMA's 2003 CPT book. It says the code applies to an "extracapsular cataract removal with insertion of intraocular lens prosthesis (one-stage procedure), manual or mechanical technique (irrigation and aspiration or phacoemulsification, for example), complex, requiring devices or techniques not generally used in routine cataract surgery (iris expansion device, suture support for intra-ocular lens or primary posterior capsulorrhexis, for example) or performed on patients in the amblyogenic developmental stage."

Keep in mind, however, that reimbursement climates differ among states. Before scheduling complex cataract cases, check your state and local medical coverage policies for these cases. These policies inform you about the diagnosis codes that support the cataract removal, the circumstances that constitute medically necessary, limitations of coverage, documentation requirements and coding guidelines (see "When to Use CPT 66982" on page 47).

Prove medical necessity
There are two components in demonstrating medical necessity to payers. The first is ensuring the operative report is consistent with the payer's coverage terms. For example, if the indication for a complex cata-ract removal is based on diagnosis of an advanced cataract, the operative report must describe the additional steps, such as insertion of ICG dye or permanent sutures, the surgeon took during the case. Secondly, the operative report must be supplemented by the proper ICD-9 diagnosis codes to support CPT code 66982. This breakdown will help guide you to the proper diagnostic codes.

• Here are a few diagnosis codes you can use when the operative report states the use of an endocapsular ring to partially occlude the pupil:
  '' 364.23 ? ? Lens induced iridocyclitis
  '' 364.51 ? ? Essential or progressive iris atrophy
  '' 364.59 ? ? Other iris atrophy
  '' 364.75 ? ? Pupillary abnormalities
  
• Here's a sampling of diagnosis codes you can use when the operative report says micro iris hooks were inserted through four separate corneal incisions, Beechler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter:
  '' 364.55 ? ? Miotic cysts of papillary margin
  '' 366.32 ? ?Cataract in inflammatory ocular disorders
  '' 366.33 ? ?Cataract with ocular neovascularization
• Here are a few ICD-9 codes you can use when the operative report says the surgeon inserted micro iris hooks through four separate corneal incisions, used a Beechler or similar ex-pansion device, created multiple sphincterotomies with scissors, performed sector iridotomy with suture repair of iris sphincter, used permanent IOL sutures to support the IOL implant, a capsular support ring or an endocapsular ring to partially occlude the pupil.
  '' 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
  '' 366.16 ? ?Senile nuclear sclerosis
  '' 366.19 ? ?Total or mature cataract
  '' 366.23 ? ?Partially resolved traumatic cataract
  '' 366.41 ? ?Diabetic cataract
  '' 366.44 ? ?Cataract associated with other syndromes
  '' 366.45 ? ?Toxic cataract
  '' 366.46 ? ?Cataract associated with radiation and other physical influences
  '' 743.46 ? ?Other specified congenital anomalies of iris and ciliary body
  '' 743.49 ? ?Other specified congenital anomalies of iris and ciliary body
• Use these ICD-9 codes for trauma cases only. The procedural description will look similar to that for the immediately preceding codes.
  '' 366.20 ? ?Traumatic cataract unspecified
  '' 366.21 ? ?Localized traumatic opacities
  '' 366.22 ? ?Total traumatic cataract
• These are miscellaneous diagnostic codes for pre-existing conditions that indicate complex cataract removal by the previously described means.
  '' 364.8 ? ? ? ?Other disorders of iris and ciliary body
  '' 364.9 ? ? ? ?Unspecified disorder of iris and ciliary body
  '' 366.30 ? ?Cataract complicated unspecified
• The following diagnosis codes would be used in conjunction with an operative report stating that the surgeon used permanent intraocular sutures or a capsular support ring to support the intraocular lens during the cataract procedure.
  '' 379.32 ? ?Subluxation of lens
  '' 379.33 ? ?Anterior dislocation of lens
  '' 379.34 ? ?Posterior dislocation of lens
  '' 743.36 ? ?Congenital anomalies of lens shape
  '' 743.37 ? ?Congenital ectopic lens
• Use ICD-9 code 364.57 when the operative report specifically says the surgeon used permanent intraocular suture or a capsular support ring to place the IOL in a stable position.
  '' 364.57 ? ?Degenerative changes of ciliary body
• Use these diagnosis codes when the operative report states the surgeon used a capsular support ring or an endocapsular support ring to partially occlude the pupil.
  '' 364.75 ? ?Iridodialysis
  '' 743.34 ? ?Aniridia
• ICD-9 codes 366.17 and 366.18 support a mature cata-ract removal, but are distinct. The operative report in each case should state that the surgeon used dye to stain the anterior capsule. However, 366.18 must be used in conjunction with diagnosis of phacolytic glaucoma (ICD-9 code 365.51).
  '' 366.17 ? ?Total or mature cataract
  '' 366.18 ? ?Hypermature cataract
• These diagnosis codes explain the circumstances for an operative note or post-op record stating that an extraordinary amount of work was involved in pre- or post-op care.
  '' 366.42 ? ?Tetanic cataract
  '' 366.43 ? ?Myotonic cataract
• These diagnosis codes may accompany cases in which the surgeon placed a prosthetic iris in the patient's eye.
  '' 379.40 ? ?Abnormal papillary function unspecified
  '' 379.49 ? ?Other anomalies of papillary function

Avoid bundling denials
One reason some ASCs lose money on complex cataracts is Medicare bundles services (including MAC anesthesia) in the facility fee. How do you get around this?

Use the most current CCI edits to determine if you need to use a modifier with the claim (see "Do You Need a Modifier?" above). These list which procedures are components of the primary cataract procedure along with indicators telling you if modifiers can be used to differentiate additional services provided. If the service or materials (specialized instruments or dye) provided constitute a distinct procedural service, you may use modifier '59 to alert the payer that separate reimbursement should be made and the extra service should not be denied as bundled in the payment.

An extra $50 may also be war-ranted if you use these lenses:

• New Technology Intra-ocular Lens Category 1 AMO Array Multifocal Model SA4ON manufactured by Allergan.
• New Technology Intraocu-lar Lens Category 2 manufactured by STAAR Surgical, which specializes in reduction of pre-existing astigmatism. This model is an elastic ultraviolet-absorbing silicone posterior chamber.

Follow the rules for multiple procedures
If the surgeon performs separate surgical procedures in addition to the cataract removal, be sure that you use supporting diagnosis codes on the separate procedures to support the medical necessity. For example, limbal relaxing incisions (CPT code 65722) may also be reimbursed when performed concurrently with a complex cataract procedure. The additional reimbursement must be justified by the use of astigmatism diagnosis codes 367.20, 367.21 or 367.22.

Lay the groundwork
To prepare for complex cata-ract cases, you can take several steps to ensure you don't lose money on the case by slowing down the case load or taking a loss on materials. Talk to your surgeon and your payers about the unusual logistics and materials involved and adjust your preparations accordingly. With thoughtful planning and sharp coding and billing practices, your ASC can host complex cataract cases without harming the bottom line.