Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Cataract Surgery billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Background

Medicare Part B program provides coverage for treatment by an ophthalmologist for certain medical conditions, including wet age-related macular degeneration (wet AMD), cataracts, and glaucoma. For these services to be covered, the service must fall within a statutorily defined benefit category, be reasonable and necessary for the diagnosis or treatment of illness, and not be excluded from coverage.

This type of surgery has been a topic of interest for the Office of the Inspector General (OIG) for a number of years. The OIG looked into surgery in both the outpatient facility and ambulatory service center settings. CMS data reflects a potential vulnerability.

Reason for Review

The SMRC was tasked with performing claim review on a sample of Cataract Surgery claims from January 1, 2019, through December 31, 2019. The SMRC conducted medical record reviews in accordance with applicable, statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• No Response to the Documentation Request
  • The requested records were not received, and the provider did not submit additional records requested. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, 42 CFR 424.5(a)(6), Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A). This requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Insufficient Documentation
  • The documentation submitted was incomplete and/or insufficient. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C; 42 CFR 424.5(a)(6), Social Security Act 1833(e), and Social Security Act 1862(a)(1)(A). The documentation submitted did not support the required documentation needed for the Cataract Surgery.
• Signature Requirements
  • The documentation submitted did not include a signed physician order or documentation to support intent to order. Refer to 42 CFR 410.32, Social Security Act 1842(p)(4), Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 and 3.6.2.2; IOM, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6; and 42 CFR 410. The documentation submitted did not include the required signatures needed for the Cataract Surgery.

References/Resources

Social Security Act (SSA) Title XVIII

• § 1815(a) Payment to Providers of Services.
• § 1833(e) Payment of Benefits.
• § 1862 (a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer.
• § 1862 (a)(7) Excludes Routine Physicals.
• § 1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
• § 1893(b) Medicare Integrity Program.

Code of Federal Regulations (CFR) Title 42

• 405.904 Determinations, Redeterminations, Reconsiderations, and Appeals under Original Medicare (Part A and Part B).
• 410.28 Hospital or CAH diagnostic services furnished to outpatients: Conditions.
• 410.32 Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and other Diagnostic Tests: Conditions.
• 411.15(k)(1) Particular Services Excluded from Coverage.
• 424.5(a)(6) Basic Conditions.
• 424.535 Revocation of enrollment in the Medicare Program.
• 416.65 Covered surgical procedures.
• 416.930(c)(2) Need to follow prescribed treatment.
• 482.24(c)(1) Condition of Participation: Medical Record Services.

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

• Chapter (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, § 140.5 Laser Procedures.
• Ch. 1, § 220.5 Ultrasound Diagnostic Procedures.

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

• Ch. 6, § 10 Hospital Services Covered Under Part B.
• Ch. 6, § 20.4 Outpatient Diagnostic Services.
• Ch. 15, § 30.1 Provider-Based Physician Services.
• Ch. 15, §30.4 Optometrist’s Services.
• Ch. 15, § 50.4.3 Examples of Not Reasonable and Necessary.
• Ch. 15, § 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.
• Ch. 15, § 80.6 Requirements for Ordering and Following Orders for Diagnostic Tests.
• Ch. 15, § 120 Prosthetic Devices.
• Ch. 16, §§ 10, 20, and 90 General Exclusions from Coverage.

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

• Ch. 1 General Billing Guidelines.
• Ch. 4, § 10 Hospital Outpatient Prospective Payment System (OPPS).
• Ch. 12, § 40.2 Billing Requirements for Global Surgeries.
• Ch. 12, § 40.4 Payment for Terminated Procedures.
• Ch. 12, § 40.6 Claims for Multiple Surgeries.
• Ch. 12, § 40.7 Claims for Bilateral Surgeries.
• Ch. 14, § 40.3 Payment for Intraocular Lens (IOL).
• Ch. 23 Fee Schedule Administration and Coding Requirements.
• Ch. 30, § 50 and 110.5.2 Financial Liability Protections.

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

• Ch. 3, § 3.2.3.2 Time Frames for Submission.
• Ch. 3, § 3.2.3.8(A) 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, § 3.6.2.1 Coverage Determinations.
• Ch. 3, § 3.6.2.2 Reasonable and Necessary Criteria.
• Ch. 3, § 3.6.2.5 Denial Types.
• Ch. 6, § 6.5.3 DRG validation.
• Ch. 13, § 13.5.4 Reasonable and Necessary Provisions in LCDs.

Local Coverage Determinations (LCDs)

• L33558. Cataract Extraction.
• L33574. Visual Field Testing.
• L33766. Visual Field Examination.
• L33808. Cataract Extraction.
• L33954. Cataract Extraction.
• L34203. Cataract Surgery in Adults
• L34394. Visual Field Testing.
• L34413. Cataract Surgery.
• L34615. Visual Fields.
• L35091. Cataract Extraction.
• L37027. Cataract Surgery in Adults.

Local Coverage Articles (LCAs)

• A52417. Visual Fields Testing – Supplemental Instructions Article.
• A53047. Billing and Coding: Complex Cataract Surgery.
• A53472. Billing and Coding: Pre/Postoperative Care: Date of Service.
• A53916. Dropless Cataract Surgery.
• A53918. Dropless Cataract Surgery.
• A56453. Billing and Coding: Cataract Extraction.
• A56544. Billing and Coding: Cataract Extraction.
• A56551. Billing and Coding: Billing and Coding for Visual Fields Testing.
• A56613. Billing and Coding: Cataract Surgery.
• A56615. Billing and Coding: Cataract Extraction.
• A56799. Billing and Coding: Billing and Coding for Visual Fields Testing.
• A56869. Billing and Coding: Use of Laterality Modifiers.
• A57195. Billing and Coding: Cataract Surgery in Adults.
• A57196. Billing and Coding; Cataract Surgery in Adults
• A57483. Billing and Coding: Visual Fields.
• A57637. Billing and Coding: Visual Field Examination.
• A56869. Billing and Coding: Use of Laterality Modifiers.

Other

• American Academy of Ophthalmology. Cataract in the Adult Eye Preferred Practice Pattern®. November 2021. Retrieved from Cataract in the Adult Eye PPP 2021 – American Academy of Ophthalmology (aao.org)

Last Updated Sep 27, 2022