Billing and Coding: Cataract Extraction (including Complex Cataract Surgery)

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35091, Cataract Extraction (including Complex Cataract Surgery). Please refer to the LCD for reasonable and necessary requirements. Coding Guidance Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. The primary diagnosis submitted by the physician performing the preoperative ophthalmologic evaluation must be cataract (ICD-10-CM codes listed in the "ICD-10 Codes that Support Medical Necessity" section of this article). The diagnoses submitted by the physician performing the evaluation and management component of the preoperative workup, when it is medically necessary, should indicate cataract (ICD-10-CM codes listed in the "ICD-10 Codes that Support Medical Necessity" section of this article) as the primary or secondary diagnosis. Complex cataract extraction should require devices or techniques not generally used in routine cataract surgery. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. When complex cataract procedures are reported the medical record must support that devices or techniques not generally used in routine cataract surgery were used, for example: Insertion of iris retractors through additional incisions Mechanical expansion of the pupil using iris hooks Creation of a sector iridectomy with subsequent suture repair of iris sphincter Use of intraoperative iris expansion device to maintain pupil dilation (i.e., Malyugin ring) iris sphincterotomies created with scissors The need to support the lens implant with permanent intraocular sutures Placement of a capsular support ring is necessary to allow secure placement of an intraocular lens