Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Part B and B of A billed on dates of service from January 1, 2022, through December 31, 2022. Below are the review results:

Background

Cataracts are the leading cause of blindness in the U.S, occurring frequently as a progressive, age-related disease. Cataracts account for 50% of visual impairment over age 40. A cataract begins to form when the lens increases in thickness and weight causing hardening and compression on the nucleus. Eventually the lens develops a yellow-brown color that changes its transparency. Cataracts can lead to blurred or distorted vision, glare, color vision defects, and a decline of contrast sensitivity and depth perception. These impairments lead to loss of balance, less independent mobility, falls, injuries, increased mortality risk, and decreased mental well-being. Visual function plays a key role in physical performance, mental well-being, and mobility, especially for the elderly. For consideration of cataract surgery, cataract patients must have an impairment of visual function due to cataract(s), resulting in the decreased ability to conduct activities of daily living such as reading, viewing television, driving, or meeting occupational or vocational expectations. Improving visual function and quality of life have increased the demand for cataract surgery.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record reviews on claims billed with Current Procedural Terminology (CPT) codes 66982, 66984, 66987, 66988, and 66989 billed with date of service January 1, 2022, through December 31, 2022. The SMRC split the data into three cohorts based on the Medicare line of business. Cohort 1 includes all Medicare Part B of A claims with 13X (outpatient hospital) type of bill (TOB). Cohort 2 includes all Medicare Part B of A claims with 85X (critical access hospital) TOB. Cohort 3 includes all Medicare Part B Professional claims.

The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Non-Response to the Additional Documentation Request (ADR)
  • The requested records were not received. Refer to 42 CFR §§ 424.5(a)(6) ,405.929, and 405.930, Social Security Act 1815(a), Social Security Act 1833(e), Social Security Act 1862(a)(1)(A), and Internet-only Manual, Pub 100-08, Chapter 3, Section 3.2.3.8. This requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request. No documentation was received in response to the ADR letter.
• Documentation Did Not Support Medical Necessity
  • The documentation submitted does not support medical necessity as listed in coverage requirements in the National Coverage Determination or Local Coverage Determination. Refer to Social Security Act 1862(a)(1)(A), Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 3.6.2.1, 3.2.2.2. Claims were denied for medical necessity when the documentation did not support one of the covered indications as outlined in the associated Local Coverage Determination.
• Incomplete or Insufficient Documentation
  • The documentation submitted was incomplete and/or insufficient. Refer to 42 CFR 424.5(a)(6), Social Security Act 1862(a)(1)(A), Social Security Act 1833(e) ), and Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C. Claims were denied if the medical record lacked the necessary information to support that coverage requirements were met. The medical record was found to be incomplete or missing required elements as outlined in the appropriate coverage policy, such as a best corrected vision, and activity of daily living difficulties, and detailed operative reports to support the services being billed.

References

Social Security Act (SSA), Title XI

• §1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• §1815(a) Payment to Providers of Services
• §1832(a)(2)(F) Scope of Benefits
• §1833(e) Payment of Benefits
• §1861(s) Medical and Other Health Services
• §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• §1862(a)(7) Exclusion of Routine Physical examinations
• §1877(g) Blanket Waivers of Section 1877(G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
• §1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed

42 Code of Federal Regulations (CFR)

• §410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions
• §411.15(k)(1) Particular services excluded from coverage
• §416.65 Covered surgical procedures
• §424.5(a)(6) Basic Conditions

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov) .
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). Effective March 1, 2020. Retrieved from CMS-1744-IFC .

Internet Only Manual (IOM), Medicare National Coverage Determination Manual (NCD), Publication (Pub). 100-03

• Ch. 1, §10.1 Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery
• Ch. 1, §§80.10-80.12 Phaco-Emulsification Procedure-Cataract Extraction and Interocular Lenses (IOLs)
• Ch. 1, §80.8 Endothelial Cell Photography
• Ch. 1, Part 2, §140.5 Laser Procedures
• Ch. 1, Part 4, §220.5 Ultrasound Diagnostic Procedures

IOM, Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Ch. 15, §30.4 Optometrist’s Services
• Ch. 15, §50.4.3 Examples of Not Reasonable and Necessary
• Ch. 15, §120 Prosthetic Devices
• Ch. 15, §260 Ambulatory Surgical Center Services
• Ch. 16, §10 General Exclusions from Coverage
• Ch. 16, §20 Services Not Reasonable and Necessary
• Ch. 16, §90 Routine Services and Appliances

IOM, Medicare Claims Processing Manual (MCPM), Pub.100-04

• Ch. 1 General Billing Guidelines
• Ch. 12, §40 Surgeons and Global Surgery
• Ch. 14, §40.3 Payment for Intraocular Lens (IOL)
• Ch. 23 Fee Schedule Administration and Coding Requirements
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)
• Ch. 30, §110 Contractor Instructions for Application of Limitation on Liability

IOM, Medicare Claims Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3, §3.2.3.2 Time Frames for Submission
• Ch. 3, §3.2.3.4 Additional Documentation Request Required and Optional Elements
• Ch. 3, §3.2.3.8 No Response or Insufficient Response to Additional Documentation. Requests
• Ch. 3, §3.3.2.1 Documents on which to Base a Determination
• Ch. 3, §3.3.2.4 Signature Requirements
• Ch. 3, §3.4.1.3 Diagnosis Code Requirements
• Ch. 3, §3.6.2 Verifying Errors
• Ch. 3, §3.6.2.4 Coding Determinations
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. Ch. 8 §§ January 1, 2021, and January 1, 2022

Local Coverage Determination (LCD)

• L33558 Cataract Extraction
• L33954 Cataract Extraction
• L35091 Cataract Extraction (including Complex Cataract Surgery)
• L34203 Cataract Surgery in Adults
• L37027 Cataract Surgery in Adults
• L38926 Cataract Extraction (including Complex Cataract Surgery)
• L34413 Cataract Surgery

Local Coverage Article (LCA)

• A56544 Billing and Coding: Cataract Extraction
• A56453 Billing and Coding: Cataract Extraction
• A56615 Billing and Coding: Cataract Extraction (including Complex Cataract Surgery)
• A57195 Billing and Coding: Cataract Surgery in Adults
• A57196 Billing and Coding: Cataract Surgery in Adults
• A58592 Billing and Coding: Cataract Extraction (including Complex Cataract Surgery)
• A56613 Billing and Coding: Cataract Surgery
• A53047 Billing and Coding: Complex Cataract Surgery: Appropriate Use and Documentation
• A53472 Billing and Coding: Pre/Postoperative Care: Date of Service
• A56869 Billing and Coding: Use of Laterality Modifiers
• A53916 Dropless Cataract Surgery
• A53918 Dropless Cataract Surgery

Other

• American Academy of Ophthalmology. Cataract in the Adult Eye Preferred Practice Pattern. September 9, 2016. Retrieved from Cataract in the Adult Eye Preferred Practice Pattern® (aaojournal.org)

Last Updated Dec 23, 2025