Claims are increasing, and it is therefore likely that scrutiny is also.
Apart from intravitreal injections, cataract with IOL implantation is the most common surgery with the Medicare program for ophthalmologists. In the 2017 Medicare Part B claims data, there were almost 1.9 million of these when you count both regular and complex surgery (CPT codes 66984 and 66982, respectively).1 This number also is 2.8% larger than the prior year, and as such represents a large expense to the program. Anything this large will have some level of payer scrutiny.
When I am asked by technicians or nurses how to properly help the surgeon document the need for cataract surgery, the questions usually center on the current vision, which is unfortunate as this can represent a misunderstanding of the importance of a functional complaint. Although current vision is important in the larger context of whether improvement is there to be gained or not, functional impairment documentation is the essential piece to support medical necessity of the procedure. It is true that payers used to focus on a minimum level of vision and a concurrent complaint before they would consider covering this procedure — but that is rarely the case now. Instead, current policies speak to the more important “functional” impairment.
Let’s examine why this is so important. Improperly documenting this can mean that if the patient would otherwise meet the specific criteria and the claim is paid but then later audited, your practice would have to return the money. Let’s look at a representative policy and see what it says so we can understand what is expected.
Palmetto GBA, a current Medicare Administrative Contractor, states these as the No. 1 and 2 reasons in support of cataract surgery in their policy2:
“Medical necessity for cataract surgery is not based solely on the presence of opacity in the lens(es). Lens extraction is considered medically necessary and therefore covered by Medicare when one (or more) of the following conditions or circumstances exists:
- Cataract causing symptomatic … impairment of visual function not correctable with a tolerable change in glasses or contact lenses, lighting, or non-operative means resulting in specific activity limitations and/or participation restrictions …
- Concomitant intraocular disease … requiring monitoring or treatment that is prevented by the presence of cataract.”
Palmetto also demands certain documentation in the chart that comports with the above. The contractor states:
- “A statement or measurements indicating that the patient’s impairment of visual function is believed not to be correctable with a tolerable change in glasses or contact lenses.
- A current best-corrected Snellen visual acuity must be recorded at a distance or near, if the primary visual impairment is near. Acuity is determined by a careful refraction … Neither uncorrected visual acuity nor corrected acuity with the patient’s current prescription will satisfy this requirement.”
It also states, “As indicated above, a Snellen visual acuity alone can neither rule in nor rule out the need for surgery, but should be considered in the context of the patient’s visual impairment and other ocular findings …
- When one or more concomitant ocular diseases are present that potentially affect visual function … the medical record should indicate that cataract is believed to be significantly contributing to the … impairment.
- A statement that the patient desires surgical correction, that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that lens surgery will significantly improve both the visual and functional status of the patient.”
This is only one payer’s opinion. But, you can see from the above that focusing only on vision is clearly misguided; other factors far outweigh it, although we must still have current and best-corrected acuity. It’s not uncommon for payers to want to see a formal, written survey of the functional impairment, and they are so strict in this that your documentation would be considered insufficient without it.3 Other payers may have policies that differ slightly from these, but overall there has been significant movement towards functional documentation of the effects of activities on daily living as the main factor, specifically when a retina or posterior segment view is not the main reason.
Proper documentation of the need for cataract surgery is imperative if we expect our practices to be able to withstand payer scrutiny afterwards. Knowledge of the specific payer policy and the requirements is key. Documentation of a functional impairment that impacts the daily living habits of our patient is almost always required. Failure to do so puts coverage of the procedure at risk.
As always, “good coding to you.” OP
- Centers for Medicare & Medicaid (CMS). 2017 Part B claims data.
- Palmetto GBA. LCD #L34413. Revision effective date 2/28/18. Link here. Accessed 01/25/19.
- Novitas Solutions, Inc. LCD #L35091. Revision effective date 08/10/17. Link here. Accessed 01/25/19.