Knowledge Base Article

A positive outlook affects our health, happiness, and even longevity. So, on the positive side, there are some advantages to getting older. Grandchildren, clearer priorities, not caring so much what others think, and retirement – to name a few. Realistically, aging also brings a whole new set of challenges. To maintain a positive position however, I will not enumerate those other than the one relevant to the subject of this article. As people age, they are very likely to develop cataracts, a clouding of the lens in the eye that affects vision. The good news is that cataracts are easily correctable and Medicare covers cataract surgery as well as the replacement intraocular lens. Even more good news, is that although Medicare does not normally cover eyeglasses or contact lenses, they cover one pair furnished subsequent to each cataract surgery with insertion of intraocular lens.

As with all services, but especially those that are high volume such as cataract surgeries, Medicare wants to ensure they are appropriately paying for these services. This means the provision of the services and the medical record documentation must meet Medicare coverage guidelines. All four of the Recovery Auditors (RACs) and CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15, are currently performing medical reviews for cataract surgery. In fact, the RACs have several issues related to cataract surgery – automated reviews to prevent billing of more than one cataract surgery per eye in a lifetime and to prevent excessive units, and a complex review of records to ensure Cataract Surgery meets Medicare coverage criteria, applicable coding guidelines, and/or is medically reasonable and necessary. The CGS targeted probe and educate (TPE) review also examines records to make sure Medicare guidelines are met. CGS has a Local Coverage Determination, as do several other MACs, describing the specific indications and limitations of coverage for the procedure.

As stated above, there are RAC review issues related to limits and excessive units.  Cataract removal can only occur once per eye during a lifetime. The RACs are looking for overpayments from providers who have billed more than one unit of cataract removal for the same eye.  Also, cataract removal cannot be performed more than once on the same eye on the same date of service. The RACs are identifying overpayments where providers have billed excessive units. This is usually the result of reporting more than one of the cataract CPT codes for the same surgery. As explained in Chapter 8 of the National Correct Coding Initiative manual, “CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye.”

Both the RACs and CGS are performing complex reviews (review of the medical record) for compliance with Medicare regulations and medical necessity of services. An example of the requirements for coverage of cataract surgery as detailed in an LCD are:

“The patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented:

• Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; and
• The patient has a best corrected visual acuity of 20/50 or worse at distant or near; or additional testing shows one of the following:
• Consensual light testing decreases visual acuity by two lines, or
• Glare testing decreases visual acuity by two lines
• The patient has determined that he/she is no longer able to function adequately with the current visual function; and
• Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the primary cause of decreased visual function; and
• Significant improvement in visual function can be expected as a result of cataract extraction; and
• The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); and
• The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and ophthalmic biometry.”

(from the CGS LCD L33594 Cataract Extraction)

CGS actually began auditing for cataract surgery in 2014 with a probe review. There were significant denial rates from the probe review so CGS progressed to targeted reviews over the next few years and then continued the review of cataract procedures into their TPE process. Initial denial rates from the probe reviews were greater than 85%, but as the providers in the CGS jurisdiction have learned the Medicare requirements and necessary supporting documentation, the denial rates have fallen to around 20% in the recent Round One TPE review results.

Although decreasing in numbers, the major denial reasons have remained basically the same. Most denials are due to missing documentation of:

• Biometry results
• Visual acuity exams
• Description of impairment of ADLs, and
• Documentation to support that cataracts are the primary cause of the patient’s decreased visual acuity.

Hospital providers need to remember that often the documentation that best supports the medical necessity of cataract removal is found in the ophthalmologist’s office notes. Copies of these notes should be included in the documentation submitted when responding to an additional documentation request (ADR) for the cataract surgery review.

One last thing to note is that Medicare only covers the insertion of a conventional intraocular lens (IOL). Special IOLs to correct presbyopia (P-C IOLs) and astigmatism (A-C IOLs) are not covered by Medicare. If a Medicare patient elects to receive either of these special lens, he/she is responsible for payment of that portion of the charge for the presbyopia-correcting or astigmatism-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery. Medicare guidance states:

• Payment for the IOL following removal of a cataract is packaged into the payment for the surgical cataract extraction/lens replacement procedure. Medicare does not make separate payment to the hospital or the ASC for an IOL inserted following removal of a cataract.
• For a P-C or A-C IOL inserted following removal of a cataract, the hospital or ASC will bill for removal of a cataract with insertion of a conventional IOL, regardless of whether a conventional or special IOL is inserted. The hospital or ASC shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL.
• The facility and physician cannot require a patient to obtain a special lens and must only perform implantation of special lens at the specific request of the patient.
• Prior to the procedure to remove a cataractous lens and insert a P-C or A-C IOL, the facility and the physician must inform the beneficiary that Medicare will not make payment for services that are specific to the insertion, adjustment, or other subsequent treatments related to the presbyopia or astigmatism-correcting functionality of the IOL. CMS strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to identify clearly the non-payable aspects of a special IOL insertion.
• In determining the beneficiary’s liability, the facility and physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring of the P-C IOL or A-C IOL that exceeds the work and resources attributable to insertion of a conventional IOL.

Providers need to be aware of Medicare’s requirements for cataract removal and IOL implantation to ensure appropriate performance, documentation and billing for these services. A great Medicare resource to help with this understanding is the Medicare Vision Services Fact Sheet. For more information about Medicare cataract services, including the annual Medicare treatment costs for select states, see the infographic on Cataracts from our sister company, Realtime Medicare Data (RTMD), in this week’s Wednesday@One.

Enjoy the vision of youth while you can, but when things get cloudy, it may be time for some cataract surgery.