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Complex Cataract Extraction with IOL and Minimally Invasive Glaucoma Surgery (MIGS) Device

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CPT 66989: Complex Extracapsular Cataract Removal with IOL and Insertion of Anterior Segment Aqueous Drainage Device

Code Description

  • Long Title: Extracapsular cataract 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, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more.
  • Short Title: CPLX CATARACT W/IOL & DRAIN
  • Explanation: This is a major combination code introduced to represent two distinct surgical objectives performed during the same operative session:
    1. Complex Cataract Surgery: The removal of a cataract and insertion of an IOL requiring advanced, time-consuming techniques (like using a Malyugin ring for a floppy iris, Trypan blue dye for a dense/mature white cataract, or managing pediatric cataracts).
    2. MIGS (Minimally Invasive Glaucoma Surgery): The insertion of a micro-drainage device (e.g., iStent inject, Hydrus Microstent) into the trabecular meshwork to lower intraocular pressure in patients with primary open-angle glaucoma.

Reimbursement & Work Details

  • wRVU: ~9.26 (Work Relative Value Units, subject to standard annual MPFS adjustments)
  • Global Period: 090 Days (Major surgical procedure)
  • Assistant Payable: No (Medicare generally restricts assistant surgeon payment for cataract and MIGS procedures).

ICD-10-CM / Diagnosis Code(s)

CRITICAL REQUIREMENT: Medical necessity for CPT 66989 requires dual diagnoses: one supporting the complex cataract extraction and one supporting the insertion of the glaucoma drainage device.

1. Glaucoma Diagnoses (Required for the MIGS portion):

  • H40.11- (Primary open-angle glaucoma): MIGS devices are strictly FDA-approved for POAG, typically mild to moderate.
    • Example: H40.1112 (Primary open-angle glaucoma, right eye, moderate stage)
    • Example: H40.1121 (Primary open-angle glaucoma, left eye, mild stage)

2. Cataract Diagnoses (Required for the Cataract portion):

  • H25.- (Age-related cataract)
    • Example: H25.11 (Age-related nuclear cataract, right eye)
  • H25.89 (Other age-related cataract): Often used for dense, mature, or brunescent cataracts that necessitate complex techniques.
  • H21.81 (Floppy iris syndrome): Highly relevant secondary diagnosis to justify the “complex” nature of the cataract surgery (e.g., requiring iris hooks).

HCC Information:

  • Yes, the glaucoma codes (H40.11-) often map to Hierarchical Condition Categories (HCCs) for risk adjustment, especially in advanced stages or specific Medicare Advantage models.
  • Cataract codes (H25.-) generally do not map to HCCs.

Bundling & NCCI Edits

Includes (Incidental/Bundled into 66989):

  • All elements of routine cataract extraction and IOL insertion.
  • The “complex” surgical techniques (e.g., Trypan blue staining, iris expansion rings, synechiolysis, primary posterior capsulorrhexis).
  • Gonioscopy (use of a specialized lens to view the anterior chamber angle) required to place the MIGS device.
  • Insertion of one or more drainage stents during the same session.
  • Ophthalmic viscoelastic devices (OVDs).
  • 90 days of postoperative care.

Exclusives / Mutually Exclusive (Cannot be billed with 66989):

  • 66991: Routine cataract surgery with anterior segment drainage device. (Mutually exclusive; you must choose between routine or complex).
  • 66982: Complex cataract surgery without MIGS.
  • 66984: Routine cataract surgery without MIGS.
  • 0191T: Insertion of anterior segment aqueous drainage device, without concurrent cataract surgery (Standalone MIGS).
  • 65820: Goniotomy. (Often bundled by NCCI when performed on the same eye at the same session as a trabecular stent).

Coding Tree & Hierarchy

  • Surgery: Eye and Ocular Adnexa (65091-68899)
    • Eyeball (65091-65290)
      • Anterior Segment (65400-66999)
        • Lens (66820-66999)
          • Extracapsular Cataract Removal (66982-66989)
            • 66982: Complex cataract extraction with IOL (No MIGS).
            • 66989: Complex cataract extraction with IOL + Aqueous drainage device.
            • 66991: Routine cataract extraction with IOL + Aqueous drainage device.

While almost universally 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: Floppy Iris Syndrome & POAG

  • Documentation: “Patient has mild primary open-angle glaucoma and a visually significant nuclear cataract in the right eye. The patient is also on Flomax, presenting with Intraoperative Floppy Iris Syndrome (IFIS). During surgery, the pupil immediately constricted, requiring the insertion of a Malyugin ring to expand the iris and safely extract the cataract. The cataract was phacoemulsified, and a posterior chamber IOL was placed. Next, the microscope was tilted, a gonioprism was applied, and two iStent inject W devices were successfully implanted into the trabecular meshwork.”
  • Coding:
    • CPT: 66989-RT
    • ICD-10 1: H40.1111 (Primary open-angle glaucoma, right eye, mild stage)
    • ICD-10 2: H25.11 (Age-related nuclear cataract, right eye)
    • ICD-10 3: H21.81 (Floppy iris syndrome)
    • Explanation: The use of the Malyugin ring elevates the cataract portion from routine to complex. The insertion of the iStents concurrently requires the use of the combination code 66989. Do not bill the cataract and the stent codes separately.

Scenario 2: Mature White Cataract (Trypan Blue) & POAG

  • Documentation: “Patient presents with moderate POAG and a mature, dense white cataract in the left eye, lacking a red reflex. Trypan blue dye (VisionBlue) was injected into the anterior chamber to stain the anterior capsule, allowing for a safe continuous curvilinear capsulorrhexis. The dense lens was phacoemulsified and a standard IOL was inserted. Following IOL placement, a Hydrus Microstent was advanced into Schlemm’s canal under gonioscopic visualization.”
  • Coding:
    • CPT: 66989-LT
    • ICD-10 1: H40.1122 (Primary open-angle glaucoma, left eye, moderate stage)
    • ICD-10 2: H25.89 (Other age-related cataract, left eye)
    • Explanation: The use of Trypan blue dye to visualize the capsule on a mature cataract qualifies as a complex technique per CPT guidelines. The addition of the Hydrus Microstent dictates the use of 66989 over 66982.

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