When an opthalmologist performs extracapsular cataract removal with IOL insertion, the correct way to code the procedure is by using CPT code 66984 [Extracapsular cataract extraction removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique ( eg, irrigation and aspiration or phacoemulsification)]. However if there are any complications encountered during surgery such as removal of dense cataracts with application of indocyanine green or trypan blue dye, pupillary enlargement, or in pediatric cases amblyogenic development stage, CPT 66982 [Extracapsular cataract extraction 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, endocapsular rings,or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage] can be used.
Note: There is a misconception among surgeons that if a surgery has taken longer than normal time, for example: to remove a dense cataract but it didn’t require any extra mechanical devices or any capsular dye for visualization, it can be considered as complex cataract.
Another misconception is that if surgeons are using presbyopia correcting IOL’s or Toric IOL’s, it qualifies as complex cataract surgery, it doesn’t. The type of IOL used during surgery doesn’t affect the case as being complex or routine cataract surgery.
Both CPT code 66982 and 66984 has a 90 day global period and if the opthalmologist performs cataract surgery in the other eye during this global period ( for example: lets say first surgery was performed on 3/2/10 in the right eye and the next surgery was performed on 4/15/10 in the left eye) then modifier -79 should be used for the subsequent surgery. Using modifier -79 will initiate a new postoperative period.