How To Use CPT Code 66988

CPT 66988 describes the procedure for extracapsular cataract removal with the insertion of an intraocular lens prosthesis using a manual or mechanical technique. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 66988?

CPT 66988 is used to describe the surgical procedure for removing an extracapsular cataract and inserting an intraocular lens prosthesis. This procedure can be performed using either a manual or mechanical technique, such as irrigation and aspiration or phacoemulsification. It is important to note that this code specifically includes endoscopic cyclophotocoagulation as part of the procedure.

2. Official Description

The official description of CPT code 66988 is: ‘Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation.’

3. Procedure

1. The provider begins by making a small incision in the eye and entering the capsule of the lens.
2. They stabilize the anterior chamber and deepen the ciliary sulcus using an ophthalmic viscoelastic device.
3. An endoscope, which contains an image guide, a light source, and a laser, is inserted into the eye to visualize the ciliary body epithelium.
4. The provider continuously visualizes the movement of the laser probe and records the images using a video camera.
5. The laser beam is directed at the ciliary processes to shrink and widen them, reducing intraocular pressure.
6. The provider then removes the hard nucleus from the lens and evacuates the soft lens cortex, leaving the capsule partially intact.
7. If phacoemulsification is used, the provider breaks up the cloudy lens using an ultrasonic device and removes the lens pieces with irrigation and aspiration.
8. Finally, the provider inserts the intraocular lens prosthesis, sutures the incision, and infuses antibiotic solution and corticosteroids into the eye.

4. Qualifying circumstances

CPT 66988 is performed on patients with cataracts, which is a clouding or opacity of the lens in the eye. The procedure is indicated when the patient requires extracapsular cataract removal and the insertion of an intraocular lens prosthesis. Additionally, endoscopic cyclophotocoagulation is performed as part of the procedure to treat or prevent glaucoma.

5. When to use CPT code 66988

CPT code 66988 should be used when the provider performs extracapsular cataract removal with the insertion of an intraocular lens prosthesis using a manual or mechanical technique, such as irrigation and aspiration or phacoemulsification. It is important to note that this code specifically includes endoscopic cyclophotocoagulation as part of the procedure.

6. Documentation requirements

To support a claim for CPT 66988, the provider must document the following information:

• Patient’s diagnosis of cataract and the need for extracapsular cataract removal
• Specific technique used for the procedure (manual or mechanical)
• Date of the procedure
• Details of the procedure, including the use of endoscopic cyclophotocoagulation
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 66988, ensure that the procedure includes extracapsular cataract removal with the insertion of an intraocular lens prosthesis using a manual or mechanical technique. It is important to note that this code specifically includes endoscopic cyclophotocoagulation as part of the procedure. There are no specific guidelines regarding reporting this code with other codes.

8. Historical information

CPT 66988 was added to the Current Procedural Terminology system on January 1, 2020. There have been no updates to the code since its addition.

9. Examples

1. A provider performs extracapsular cataract removal with the insertion of an intraocular lens prosthesis using phacoemulsification and endoscopic cyclophotocoagulation.
2. During the procedure, the provider uses a manual technique for extracapsular cataract removal and inserts an intraocular lens prosthesis, along with performing endoscopic cyclophotocoagulation.
3. A patient undergoes extracapsular cataract removal with the insertion of an intraocular lens prosthesis using irrigation and aspiration, along with endoscopic cyclophotocoagulation.
4. The provider performs extracapsular cataract removal with the insertion of an intraocular lens prosthesis using phacoemulsification and endoscopic cyclophotocoagulation, along with suturing the incision.
5. During the procedure, the provider uses a manual technique for extracapsular cataract removal and inserts an intraocular lens prosthesis, along with performing endoscopic cyclophotocoagulation and infusing antibiotic solution and corticosteroids into the eye.