Did you know that approximately 1 in 5 individuals aged between 65 and 74 have cataracts that affect their vision in the US? That’s not all, over 50% of people older than 80 years either have cataracts or have had surgery to remove them.
Ophthalmologists work hard to ensure the eye health of these individuals nationwide, and deserve to be reimbursed fairly. Thus, we dedicated this guide to discussing the billing guidelines related to one critical procedure covered under CPT code 66821.
From clinical scenarios to applicable modifiers, we will cover all. So, continue reading!
CPT Code 66821 – Description
CPT code 66821 covers YAG laser capsulotomy. It involves using a laser to remove haziness from the capsule of the patient’s eye. The procedure is typically performed in cases where the patient has a secondary membranous cataract.
Scenarios Where CPT Code 66821 is Applicable
Let’s review a few real-world clinical scenarios related to CPT 66821:
Visually Significant Posterior Capsular Opacification (PCO)
Picture a 65-year-old female patient who visits the ophthalmologist one year after a successful cataract surgery in the right eye. She complains about experiencing a gradual return of foggy or cloudy vision. Besides, she is having difficulty reading small print.
The ophthalmologist performs a slit-lamp examination. It reveals significant wrinkling and opacification of the posterior lens capsule. Precisely speaking, the best corrected visual acuity (BCVA) has declined from 20/20 post-cataract surgery to 20/50.
As a result, the physician conducts a YAG laser capsulotomy to create a clear opening in the center of the opacified capsule. Post procedure, the visual axis is cleared, and the patient’s BCVA returns to 20/20.
Hence, CPT code 66821 will be reported to bill for post-cataract laser surgery.
Debilitating Glare and Night Driving Difficulty
Consider a 71-year-old male patient who complains about severe glare and halos around the headlight while driving at night. He has 20/30 vision in his left eye, but due to the condition, he feels unsafe driving after sunset.
The slit-lamp examination reveals pearl-type PCO migrating toward the visual axis. Additionally, a glare test showed that his vision has dropped from 20/30 to 20/70.
Thus, the ophthalmologist performs YAG laser surgery (CPT code 66821) to remove the secondary cataract causing light scatter.
Post procedure, the patient reports immediate resolution of night-driving halos.
Obstructed View During Retinal Disease Management
Imagine a 59-year-old female patient with a history of proliferative diabetic retinopathy. As a result, she requires regular intravitreal injections and retinal laser photocoagulation to manage the disease.
However, on a recent visit, the ophthalmologist identified a thickening of the posterior capsule that obstructs the view of the fundus. The condition makes it impossible to safely perform retinal treatments or monitor for new vessel growth.
Thus, the physician performs a YAG laser capsulotomy to provide a clear “window” for the surgeon to treat the underlying retinal pathology.
Here, CPT code 66821 applies.
Applicable Modifiers for CPT Code 66821
Discussed below are some of the applicable modifiers related to CPT 66821:
Modifier 50
Did you perform the YAG laser capsulotomy procedure on both eyes during the same surgical session? If yes, report CPT code 66821 with modifier 50 to indicate bilateral service.
Modifier 51
What happens when you perform another distinct, significant service with the post-cataract laser surgery (CPT code 66821) during the same session? You append modifier 51 to indicate multiple services and separate reimbursement for both.
Note that you will receive 100% payment for the primary service (with a higher dollar amount) and get a 50% reimbursement rate for the secondary service.
Modifier 78
There may be scenarios where you have to perform the YAG laser capsulotomy during the post-operative period of the initial cataract surgery (CPT 66984).
When this happens, append modifier 78 to CPT code 66821. It will indicate to the payer that the patient returned to the operating room for a related procedure and was treated by the same physician.
Modifier LT
Modifier LT is an anatomical modifier that identifies that you performed the YAG laser capsulotomy on the left eye of the patient.
Modifier RT
Similar to LT, RT is also an anatomical modifier. It highlights to the payer that the procedure covered under CPT code 66821 was performed on the right eye.
CPT Code 66821 – Billing & Reimbursement Guidelines
The following are some essential billing guidelines for CPT 66821:
Understand the 90-Day Global Period
CPT code 66821 is a major procedure with a 90-day global period. Simply put, it means that the reimbursement for the YAG laser capsulotomy covers everything listed below:
- Routine exams (conducted the day before or the day of the laser surgery).
- All usual and necessary parts of the laser procedure.
- Every routine follow-up visit during the 90-day post-operative period, related to the recovery from the laser.
- Treatment of standard complications, such as minor inflammation that does not require a return to the operating room.
Fulfill Documentation Requirements
Detailed documentation helps establish medical necessity and supports the modifier usage. Below is a checklist to ensure documentation completeness and accuracy while billing for CPT code 66821:
- Describe the unique chief complaint. That is, the specific functional symptoms, such as ‘glare, make reading impossible’.
- Explicitly state that the vision loss interferes with daily tasks.
- Record the BCVA findings.
- In some cases, you may also need to document a glare test or contrast sensitivity test.
- Mention the results of the slit-lamp examination, e.g., secondary cataract.
- Include details of the laterality, i.e., which eye was treated, e.g., left, right, or bilateral.
- State the number of pulses or spots and total energy delivered.
- Describe the anesthetic/dilation drops used.
- Mention details related to post-operative instructions, including activity guidelines, medications, and follow-up visits.
Append Appropriate Modifier
Coding specificity is fundamental for rightful reimbursement and ensuring compliance. Thus, you should append appropriate modifiers while reporting post-cataract laser surgery.
Some of the applicable modifiers include 50, 51, 78, LT, and RT. We have discussed more about their appropriate usage in the ‘Applicable Modifiers for CPT Code 66821’ section.
Summary
After reading this guide, you can easily streamline your billing workflow for YAG laser capsulotomy (CPT code 66821).
However, do not forget to use the appropriate modifier to specify whether the surgery was performed on the left eye (LT), right eye (RT), or both eyes (50). Moreover, be wary of the 90-day global period for this procedure.
In case you want to partner with professionals to handle the billing intricacies related to this or other procedures, feel free to partner with MediBillMD for ophthalmology billing services.
