18.2 Eye and Ear Surgery
Key Takeaways
- Cataract extraction codes in the 66830–66991 range are mutually exclusive for one eye; 66984 is the ordinary extracapsular-with-IOL family and 66982 is used only when the record supports a complex extraction
- Iridectomy or limited vitrectomy done only to complete cataract extraction is bundled; antibiotic or steroid injection during cataract surgery is not reported as 67028
- Facility claims still report today's eye or ear procedure; the surgeon's professional 90-day global package does not delete the HOPD or ASC line
- Use RT/LT for eyes and ears, and E1–E4 before LT/RT for eyelids; hospital OPPS bilateral surgery that takes 50 is typically one line and one unit, while Medicare ASC bilateral surgery uses two lines with LT and RT
- Myringotomy is included in tympanoplasty or tympanostomy; do not add a second ipsilateral mastoidectomy code when the primary descriptor already includes mastoidectomy; Medicare rarely pays 69990 with otologic cases
18.2 Eye and Ear Surgery
Quick Answer: For cataract, intravitreal injection, strabismus, tympanostomy, tympanoplasty, and mastoid work, code the eye or ear that was operated, apply RT/LT (or E1–E4 for eyelids), and obey NCCI same-structure bundling. 66984 is the ordinary extracapsular cataract extraction with intraocular lens (IOL) family; 66982 is complex only when the record supports it. The surgeon's professional global surgical package does not erase the facility line.
Independent OpenExamPrep teaching for COC candidates stays at decision rules. Do not memorize a wall of ophthalmology CPT descriptors. AAPC's surgery-and-modifiers domain tests procedures approved for outpatient hospital and ASC facilities. OpenExamPrep does not claim AAPC, CMS, or AMA approval.
Why laterality and bundling beat a code list
Eyes and ears are paired organs. A perfect family choice with the wrong side still fails. NCCI Chapter VIII §H.5: bilateral ophthalmic procedures on practitioner and outpatient hospital claims that take modifier 50 are reported with modifier 50 and one unit of service on a single claim line. Eyelid procedures use E1–E4 (upper left, lower left, upper right, lower right) before LT/RT/59 (MCPM Chapter 4 §20.6). Medicare ASC bilateral surgical reporting is two lines, LT and RT, one unit each—the hospital 50 pattern does not apply to an ASC (NCCI Chapter VIII §H.9). Read the stem's setting before you build the line.
Global versus facility. Cataract extraction is a major professional surgery (090-day global on the surgeon's claim). Postoperative visits, typical medications, and the decision-for-surgery rules live on the CMS-1500. The HOPD or ASC still reports the procedure performed today. Do not omit 66984 from the UB-04 or the ASC facility claim because the surgeon is "in global." Do not copy professional modifier 24 or 79 onto the facility line as a default. NCCI Chapter VIII §B restates those professional Evaluation and Management (E/M) global rules; MCPM Chapter 4 and prior OpenExamPrep modifier teaching already warned that hospitals do not swallow today's surgery into the surgeon's global days. OPPS packaging and NCCI PTP edits still apply to the facility claim.
Cataract: 66984 family, complex cataract, and the IOL
Open the cataract subsection for the technique that was completed, not the booking title.
66984 conceptually is extracapsular cataract removal with IOL insertion, one stage, one eye—the ordinary phacoemulsification-with-lens case. 66982 is complex cataract surgery: the record must support complexity (examples CPT contemplates include a miotic pupil requiring devices, pediatric cataract, and other documented extra intraoperative work). A difficult case that still meets only the ordinary descriptor is still 66984. Intraocular lens insertion is in those extraction-with-IOL codes. Secondary IOL placement or exchange without a concurrent cataract extraction is a different family (think 66985/66986 conceptually)—do not use 66984 because "a lens went in."
NCCI Chapter VIII §D.3: cataract extraction codes 66830–66991 are mutually exclusive. Only one code from that range is reported for an eye. Do not stack 66984 and 66982 because the title said "possible complex."
Bundling that finishes the extraction. NCCI Chapter VIII §D.2: iridectomy performed to complete the cataract extraction is integral. Minimal vitreous loss during routine extraction is not a separately reported vitrectomy. A truly separate and distinct iridectomy or vitrectomy for an unrelated reason may be reported with an NCCI PTP-associated modifier when the record proves distinct medical necessity. A trabeculectomy done as the appropriate glaucoma operation at the same encounter may be separately reportable with a PTP-associated modifier; a trabeculectomy done only to prevent an expected transient postoperative pressure spike, without other evidence of glaucoma, is not separately reportable.
NCCI Chapter VIII §D.20: injection of an antibiotic, steroid, or nonsteroidal anti-inflammatory drug during cataract extraction (or another ophthalmic procedure) is not separately reportable. Do not add 67028, 66020, 66030, 67500, 67515, or 68200 for that finishing injection. Anesthesia injections by the operating surgeon are not separately reported (§D.11). Repair of the surgical corneal, scleral, or conjunctival incision is integral; do not use laceration-repair codes for closing your own incision (§D.16–D.18).
IOL as a device/supply. The extraction-with-IOL CPT describes the procedure. The lens implant still needs a Healthcare Common Procedure Coding System (HCPCS) device or supply line when the facility purchased the lens, subject to OPPS packaging versus separately payable status and, in the ASC, the current payment indicator (including any new technology IOL extra payment when CMS has assigned it). Do not invent a lens HCPCS the implant log does not support. Confirm current Addendum B (HOPD) or Addendum AA/BB (ASC) rather than assuming every IOL is a second APC.
Intravitreal injections and high-level strabismus
67028 is intravitreal injection of a pharmacologic agent, a CPT separate procedure. When the encounter is an office or facility injection clinic, report 67028 with RT or LT (hospital bilateral: 50 and one unit when 50 applies; ASC: LT/RT on two lines). Report the drug with the correct HCPCS and units; OPPS still packages many drugs under the CY 2026 $140 threshold and pays others under status indicator G or K. NCCI Chapter VIII §D.25: do not add ipsilateral 68200 (subconjunctival injection) with 67028. §D.24: do not report 67028 with anterior-chamber paracentesis 65800–65815 on the same eye, same encounter—Medicare does not allow two "separate procedure" codes in the same anatomic region at one encounter. Posterior-segment surgeries in 67005–67229 include extended ophthalmoscopy on that date (§D.19).
Strabismus stays high-level on the COC: identify which extraocular muscles were recessed, resected, or otherwise operated, how many, and which eye(s). Horizontal versus vertical work and adjustable sutures, when documented, change the family. Do not pick a code from the schedule line "strabismus repair." Do not unbundle forced duction testing or routine exploration of the same muscles. Laterality still belongs on paired eyes.
| Eye/ear decision | Facility reporting | Common unbundle |
|---|---|---|
| Ordinary cataract with IOL, one eye | One code from the 66984 family; RT or LT | Second cataract code from 66830–66991 on the same eye |
| Documented complex cataract | 66982 family when the note supports complexity | 66982 because the case took longer |
| Iridectomy only to deliver the nucleus/IOL | Included in the extraction | Separate iridectomy "because it is listed" |
| Antibiotic/steroid given during cataract | Included | 67028 or 68200 |
| Intravitreal drug as the service | 67028 plus laterality plus drug HCPCS | Ipsilateral 68200 or same-eye paracentesis |
| Eyelid procedure | E1–E4 before LT/RT | Modifier 59 because two lids were mentioned |
| Tympanostomy tube | 69433 (local) versus 69436 (general); laterality/bilateral rules | Separate myringotomy |
| Tympanoplasty whose descriptor includes mastoidectomy | One combination family | Extra ipsilateral mastoidectomy 69502–69511 |
Tympanostomy, tympanoplasty, mastoid
Tympanostomy (ventilation tube) splits by anesthesia: 69433 under local, 69436 under general. Bilateral tubes are everyday pediatric ASC cases. Apply the same setting-specific bilateral construction already taught: hospital OPPS often 50 / one unit; Medicare ASC LT and RT on two lines. The tube supply is not automatically a separately payable HCPCS on a packaged facility claim.
NCCI Chapter VIII §E.2: a myringotomy (69420, 69421) is included in a tympanoplasty or tympanostomy and is not separately reportable. §E.3: if the otologic procedure uses a transcanal or endaural approach with incision of the tympanic membrane and access through the middle ear, exploration of the middle ear (69440) and tympanic-membrane procedures (including 69433/69436 and related myringoplasty-type codes) are not separately reported. §E.1: if the code descriptor includes a mastoidectomy (examples NCCI names include 69530 and 69910), do not add 69502–69511 for the ipsilateral mastoid.
Tympanoplasty families conceptually separate without mastoidectomy from with mastoidectomy, and they further distinguish canal-wall-up versus more extensive mastoid work when the descriptor requires it. Code the completed reconstruction, including ossicular work only when documented. Do not add a standalone mastoidectomy because the microscope was draped toward the mastoid air cells for orientation.
Operating microscope 69990. NCCI Chapter VIII §F: CMS Internet-Only Manual, MCPM Chapter 12 §20.4.5, limits separate 69990 payment to a short list of mostly intracranial, spinal, and nerve-repair codes. 69990 is bundled into all other surgical procedures, including typical otologic microsurgery, and most of those edits do not allow an NCCI-associated modifier. Using a microscope is not a 69990 on a tympanoplasty claim.
Facility scenario
On-campus HOPD: right phacoemulsification with posterior-chamber IOL. Small-pupil stretch is not described. A peripheral iridectomy is documented only to complete nucleus delivery. Intracameral antibiotic is given. Facility: 66984-RT, IOL HCPCS per the implant log and current OPPS status, no separate iridectomy, no 67028. The surgeon's 090-day global is on the professional claim with POS 22; it does not delete the hospital 13X surgery line.
ASC the next week: bilateral myringotomy with tube insertion under general anesthesia. Facility: 69436 on two lines with LT and RT (Medicare ASC), not a copied hospital single line with 50, and no 69420. Confirm 69436 is on the ASC CPL—which it has long been—rather than treating every ear case as automatically CPL-eligible after CY 2026's 289 and 271 additions.
Sources
A hospital outpatient cataract extraction includes a peripheral iridectomy performed only to complete nucleus delivery, plus an intracameral antibiotic at the end of the case. Which NCCI Chapter VIII reporting is correct for that eye?
When is CPT 67028 the correct facility injection code, and what is bundled with it on the ipsilateral eye?
A Medicare ASC note documents tympanoplasty whose CPT descriptor includes mastoidectomy, plus incision of the tympanic membrane for access, under the operating microscope. Which bundling and laterality statement is correct?