Crystal's MCW Coder HubCPT 66850: Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration
Code Description
- Long Title: Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration
- Short Title: REMOVAL OF LENS MATERIAL
- Explanation: This procedure involves the surgical removal of the eye’s crystalline lens (typically due to a cataract or retained lens fragments) utilizing a phacofragmentation technique. The surgeon uses an ultrasonic or mechanical device (phacoemulsification) to break the lens material into tiny pieces and aspirates (suctions) them out of the eye.
- CRITICAL CODING NOTE: This code does NOT include the insertion of an intraocular lens (IOL) prosthesis. If an IOL is inserted during the same operative session, you must use a different code (such as 66984 for standard cataract extraction with IOL, or 66982 for complex). CPT 66850 is typically used when a patient cannot safely receive an IOL, or more commonly, when removing retained lens fragments from a previous complicated cataract surgery.
Reimbursement & Work Details
- wRVU: 10.55 (Work Relative Value Units, subject to standard MPFS adjustments)
- Global Period: 090 Days (Major surgical procedure)
- Assistant Payable: No (Medicare applies a statutory payment restriction for assistants at surgery for this procedure).
ICD-10-CM / Diagnosis Code(s)
Primary Diagnoses Commonly Supporting Medical Necessity:
- H59.02- (Cataract (lens) fragments in eye following cataract surgery): Very common indication for this standalone code.
- Example: H59.021 (Cataract (lens) fragments in eye following cataract surgery, right eye)
- H25.- (Age-related cataract): Requires 5th/6th characters for type and laterality.
- Example: H25.11 (Age-related nuclear cataract, right eye)
- H26.- (Other cataract): Includes infantile, juvenile, presenile, or traumatic cataracts.
- Example: H26.111 (Localized traumatic opacities, right eye)
- H27.0- (Aphakia): Used if the patient is already missing a lens but has retained cortex material.
HCC Information:
- ICD-10 codes in the H25 and H26 (Cataracts) range generally do not map to a Hierarchical Condition Category (HCC) for risk adjustment.
Bundling & NCCI Edits
Includes (Incidental/Bundled into 66850):
- Local or topical anesthesia (e.g., retrobulbar or peribulbar block).
- Creation of the corneal or scleral incision.
- Capsulotomy/Capsulorrhexis (opening the lens capsule).
- Phacoemulsification and aspiration of the lens material.
- Closure of the incision (whether by hydration or sutures).
- Standard postoperative follow-up care within the 90-day global period.
Exclusives / Mutually Exclusive (Cannot be billed with 66850):
- 66984: Extracapsular cataract removal with insertion of intraocular lens prosthesis. (Mutually exclusive; if an IOL is placed, 66850 is bundled into 66984).
- 66982: Extracapsular cataract removal with insertion of intraocular lens prosthesis, complex.
- 66840: Removal of lens material; aspiration technique, 1 or more stages. (Cannot bill two different lens removal techniques on the same eye at the same session).
- 67036: vitrectomy, mechanical, pars plana approach. Note: If lens material has dropped into the posterior segment and a retinal specialist performs a pars plana vitrectomy to retrieve it, CPT 66852 (Removal of lens material; pars plana approach) or vitrectomy codes are more appropriate depending on the exact documentation.
Coding Tree & Hierarchy
- Surgery: Eye and Ocular Adnexa (65091-68899)
MS-DRG (Medicare Severity Diagnosis Related Group)
While typically performed in an Outpatient/Ambulatory Surgery Center (ASC) setting, if performed inpatient, it maps to:
- MS-DRG 124: Other Disorders of the Eye with MCC.
- MS-DRG 125: Other Disorders of the Eye without MCC.
Coding Examples & Scenarios
Scenario 1: Retained Lens Fragments
- Documentation: “Patient is 2 weeks post-op from a complicated cataract surgery on the left eye and presents with severe inflammation due to retained cortical lens fragments in the anterior chamber. The patient was taken back to the OR. A paracentesis was made, and the phacoemulsification handpiece was introduced. The remaining lens fragments were emulsified and aspirated completely. The incisions were hydrated and sealed.”
- Coding:
- CPT: 66850-78-LT (Modifier 78 indicates an unplanned return to the OR for a related procedure during the global period of the initial cataract surgery).
- ICD-10: H59.022 (Cataract (lens) fragments in eye following cataract surgery, left eye).
- Explanation: Since no new IOL was inserted and the surgeon used phacoemulsification to remove the retained material, 66850 is the perfect fit.
Scenario 2: Aborted IOL Placement
- Documentation: “Planned cataract extraction with IOL on the right eye. The dense nuclear sclerotic cataract was successfully broken up and removed using ultrasonic phacofragmentation. However, during the procedure, a massive posterior capsule rupture occurred with vitreous prolapse. It was determined that the eye could not safely support an IOL at this time. An anterior vitrectomy was performed, and the eye was closed. The patient will return at a later date for a secondary IOL.”
- Coding:
- CPT: 66850-RT - ICD-10: H25.11 (Age-related nuclear cataract, right eye), plus a secondary code for the capsular tear/complication if documented.
- Explanation: Because the intraocular lens (IOL) was not successfully inserted, you cannot bill 66984 or 66982. The service is downgraded to 66850 to reflect solely the removal of the lens material. (The anterior vitrectomy 67010 may be billable or bundled depending on payer rules regarding iatrogenic complications, but 66850 represents the primary lens extraction).