01-302 Cataract Surgery Notification of Medical Review
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:
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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 184.108.40.206 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 220.127.116.11 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 18.104.22.168 and 22.214.171.124; 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.
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, § 126.96.36.199 Time Frames for Submission.
- Ch. 3, § 188.8.131.52(A) Additional Documentation Requests.
- Ch. 3, § 184.108.40.206 Documents on which to Base a Determination.
- Ch. 3, § 220.127.116.11 Signature Requirements.
- Ch. 3, § 18.104.22.168 Diagnosis Code Requirements.
- Ch. 3, § 22.214.171.124 Coverage Determinations.
- Ch. 3, § 126.96.36.199 Reasonable and Necessary Criteria.
- Ch. 3, § 188.8.131.52 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.
- 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