Medicare Reimbursement for Mechanical Pupil Dilation with OASIS Iris Expander (OASIS Medical)

FREQUENTLY ASKED QUESTIONS: 

MEDICARE REIMBURSEMENT FOR MECHANICAL PUPIL DILATION WITH OASIS IRIS EXPANDER

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Q  What is the OASIS® Iris Expander?

A  The OASIS Iris Expander is a temporary surgical implant to assist the surgeon with mechanical dilation of a small pupil that is refractory to pharmacological dilation.  It is constructed of polypropylene material and uses a disposable injector.

The Iris Expander provides stable mydriasis during cataract surgery with no trauma to the iris tissue and no need for additional paracenteses.  The capsulorrhexis, hydrodissection, phacoemulsification, and injection of the IOL may occur with the device in place.  At the conclusion of the procedure, the surgeon removes the Iris Expander from the eye.

 

Q  What are the indications for use of the Iris Expander?

A  Mechanical pupillary stretching is indicated in cases where topical or intracameral mydriatics are inadequate for proper dilation or are contraindicated.  Most often these cases involve small pupils with rigid iris tissue from pseudoexfoliation, posterior synechiae, or prior use of miotics.  In some cases of intraoperative floppy-iris syndrome (IFIS) with a constricted pupil, mechanical pupil dilation is necessary. 

 

Q  Does use of the Iris Expander qualify as complex cataract surgery?

A  Yes.  One aspect of complex cataract surgery is mechanical dilation of a small pupil to enable the surgeon to extract the cataract and implant an IOL.

 

Q  What CPT code describes complex cataract surgery?

A  CPT code 66982 describes “Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage.” 

 

Q  What are supportive diagnosis codes for 66982?

A  Most payers require two diagnoses to support a claim for complex cataract surgery.  In addition to a primary cataract diagnosis, some acceptable secondary codes include:

Check with your local Medicare Administrative Contractor (MAC) for a list of suitable ICD codes in your area. 

*  A dash (-) at the end of an ICD-10 code indicates that there are more digits to follow.

 

Q  What does Medicare allow for 66982?

A  In 2016, the national Medicare Physician Fee Schedule allowable for 66982 is $806.  This amount is adjusted by local wage indices in each area.  Reimbursement is about 24% higher than the Medicare rate for regular cataract surgery with IOL (66984).  Other payers set their own rates, which may differ significantly from the Medicare published fee. 

 

Q  Is 66982 subject to NCCI edits?

A  Medicare’s current National Correct Coding Edits (NCCI) include bundles associated with 66982.  They are substantially the same as the bundles associated with 66984.

 

Q  Is 66982 eligible for facility reimbursement?

A  Yes.  In 2016, the national Medicare allowable for 66982 in a hospital outpatient department (HOPD) is $1,746; for an ASC, it is $976.  The same payment rates apply to 66984.  This amount is adjusted by local indices in each area.

 

Q  Is there additional payment for the OASIS Iris Expander itself?

A  No.  The device is included in the reimbursement for the facility fee, and the hospital or ASC is precluded from balance billing the beneficiary for it.  So, even though the surgeon receives additional reimbursement for complex cataract surgery, the ASC and HOPD do not.

 

Q  How frequently would 66982 be used?

A  Not often.  Of all Medicare claims paid during 2014, complex cataract surgery accounts for just 10% of all cataract extractions with IOL.  However, ophthalmic practices vary and some surgeons may perform this procedure more frequently by virtue of the extraordinary populations they serve.  Other surgeons may elect to avoid these difficult cases altogether and never report 66982.

 

Q  Must complex cataract surgery with an OASIS Iris Expander be planned in advance?

A  No.  The CPT definition of complex cataract surgery is task-based.  While a surgeon might know if mechanical pupil dilation is likely, it’s not always needed.  Plans can change during the operation.  Don’t report 66982 if you initially plan to mechanically dilate the pupil but find it unnecessary to do so during the procedure, and vice versa.

 

Provided Courtesy of OASIS Medical, Inc.  (800) 528-9786

 

Last updated March 22, 2016

 

The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-9 and ICD-10), and official instructions promulgated by Medicare and other payers.  This document is not an official source nor is it a complete guide on reimbursement.  The reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.

 

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