Billing and Coding: Complex Cataract Surgery: Appropriate Use and Documentation

CPT 66982 (complex cataract surgery) is covered only when nonroutine devices or techniques are required (for example: iris retractors/hooks, Malyugin ring, iris sphincter repair, capsular support ring, intraocular sutures, intraocular dye, or pediatric cataract surgery). Surgeon-perceived difficulty, extra operative time, or conditions such as pseudoexfoliation without need for special devices do not justify 66982; claims must be supported by complete operative documentation and must meet any applicable LCD requirements.

"Billing CPT 66982 is appropriate when insertion of iris retractors through additional incisions was required to perform the cataract extraction."

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