ASC Coding Tip: Properly Coding Complex Cataract Extraction

On the Ambulatory Surgery Center Association's (ASCA) discussion board, an ASCA member asked for assistance with cataract billing. The question was essentially as follows: "I have a surgeon wondering if he can bill complex cataract extraction (CPT 66982) if he performs a manual pupil stretch. I was under the impression that the only reasons a cataract extraction could be constituted as complex would be if an outside device, like iris retractors, iris hooks, or ring (e.g., capsular tension/Malyugin) were used. The use of trypan blue dye used to be associated with complex cataract extraction, but that was removed as a reason years ago. Is manual pupil stretch a valid reason?"

Let's dive into this question. Complex cataract surgery selection is determined by the use of techniques not generally performed during routine cataract surgery.

As per the 2024 AMA CPT Code book, let's look at the two CPT codes for cataract extraction without endoscopic cyclophotocoagulation:

• 66984, used for noncomplex cataract extractions, is defined as follows: 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
• 66982, used for complex cataract extractions, is defined as follows: 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 in the amblyogenic development state; without endoscopic cyclophotocoagulation

Cataract procedures require manual or mechanical techniques to qualify as complex and receive CPT 66982. The March 2016 CPT Assistant states the following: "The presence of a miotic pupil that will not dilate sufficiently to allow operative access to the lens, which requires the insertion of one of the following: four iris retractors through four additional incisions; a Beehler expansion device; a sector iridectomy with subsequent suture repair of; an iris sphincter; or sphincterotomies created with scissors."

Per this guidance, manual expansion of the pupil without the use of tools/techniques would not qualify as a complex cataract case. "Complex" requires extraordinary techniques. The September 2009 CPT Assistant notes: "Dilation of the iris by manually stretching it with a hook inserted through the same incision does not justify the use of code 66982. However, the use of a special pupil-stretching device such as a Beehler pupil stretcher or other such similar devices does justify the use of the use of this code."

With all of this said, the answer to the ASCA's member's question is that their surgeon cannot bill complex cataract extraction when he performs a manual pupil stretch.

ASC coders should carefully review the surgeon’s documentation to determine what tools/techniques were used, which guides the coder to the correct CPT code for the cataract surgery performed.