Optometrist's Guide to Billing Cataract Post-Op Care

With cataract surgery the most commonly performed surgical procedure in the United States (an estimated 3.5 million surgeries are done each year by ophthalmologists in the US!), optometrists take on the majority of post-operative care needs for these patients. Typically the ophthalmologist who performed surgery sees the patient for a 1 day post-op visit, and then releases care to a partnering optometrist for the 1 week and subsequent follow-up visits over the 90 day post-operative period. Optometrists are trained and skilled at handling post-operative care and complications, but handling the billing and coding for post-operative care poses unique challenges because insurances require that the doctor split reimbursements with the surgeon who performs the surgery and who who initiates the post-op care on day 1. If you need a quick reference on filling out insurance claims for post-operative cataract surgery care, this guide is for you!

When you see the patient for their initial post-op visit under your care, you will file CPT code 66984-EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS

• Link this code to the cataract in the eye that just had surgery. Yes, I know there is no cataract now during your post-op care because surgery was done to remove it. But your post-op care is getting partial payment from insurance for the overall procedure, so you're linking it to the cataract that used to be there. It is important that you use the same cataract code that the operating surgeon did. If the codes don't match, insurance will reject. Most surgeons use H25.81X Combined Forms of Age-Related Cataract, but make sure you match what was used in the transfer of care document sent by the surgeon.
• use modifier -55 Post-Operative Management
• use modifier -LT or -RT pending which eye was operated on (and make sure you've linked that to the appropriate cataract code H25.811 for right eye, H25.812 for left eye)
• use modifier -79 if you are initiating post-operative care for the second eye during the global period of the first eye's cataract surgery post-op care

Example of a cataract post-op claim filed to BCBS. This claim was approved and paid by insurance!

On the claim you'll have to fill out some additional information; if this is missing, your claim will likely be denied. 

• Initial Treatment Date: this is date of SURGERY not the date that you initiate care for post-op visits!
• Place of Service (pick 11 "office" in most cases of primary eyecare setting)
• Units = 1 
• Box 17 = Referring surgeon’s name and NPI (I have had good success just listing the referring provider's name)
• Box 19 = Dates of assumed care. The first date is the date you see the patient for your first post-op visit; the last date is the final date in the 90 day global period*
• Remember to link the CPT service code to the diagnosis code for cataract that was used by the surgeon at the time of surgery!

Note in the additional claim information section you put the referring doctor (Box 17), initial treatment date (SURGERY DATE!), report care start date is your first day of post-op care, and report care end date is the last day of the 90 day global period. I always spell it all out in Box 19 too.

*You will only file this 66984-55 code on the day you initiate your cataract surgery post-op care. This code has a 90 day global period of care covered under its' reimbursement, starting from the day of surgery. You can calculate the 90 day global period end date with this easy Palmetto Medicare calculator.

Every insurance has different allowables for what the reimburse for services. With Medicare, cataract post-op care reimburses at a rate of 20% of the reimbursement of the surgery itself, and then Medicare pays 80% of that amount to the provider as the "allowed" pay rate. With current reimbursement schedules that comes to:

Cataract Surgery 66984 reimburses $510.83

Cataract Surgery Post-Op Care 90 Days 66984-55 at 20% = $102.17

80% "allowed" pay rate by Medicare = $81.73 total 

If you file incorrectly, I've seen doctors get reimbursed 80 cents before for post-op care. So it's important with how little reimbursement there is for the 90 days of visits to make sure you receive the full allowed rate from insurance. And yes, this very low reimbursement rate is a major factor why most ophthalmologists do not provide post-op care, but that is another post.