01-125 Cataract Surgery Notification of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting 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. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
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 is 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 will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.
Claim Sample Detail
| CPT | Description |
|---|---|
| 66982 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation |
| 66984 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation |
| 66987 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation |
| 66988 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation |
| 66989 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more |
| Cohort | Description |
|---|---|
| Cohort 1 (13X TOB) | Medicare Part B of A Outpatient Hospital |
| Cohort 2 (85X TOB) | Medicare Part B of A Critical Access Hospital |
| Cohort 3 (Medicare Part B Professional) | Medicare Part B Professional claims |
Access related project details below.
Documentation Requirements
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.
Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.
- Operative or procedure report for the claim’s billed dates of service.
- History and Physical reports including pre and post operative progress notes related to Cataract Surgery.
- Signed Consent form when a bilateral procedure is performed.
- Comprehensive preoperative ophthalmologic evaluation including but not limited to: examination or testing, best corrected Snellen visual acuity, corrected vision with glasses or contacts, and support that visual impairment effects activities of daily living.
- All Visual Field Testing and documentation.
- Diagnostic Studies, including visual acuity and glare tests.
- Documentation to support medical necessity for the cataract surgery.
- Documentation supporting the diagnosis code(s) required for the item(s) billed.
- Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article.
- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC).
- Any other supporting or pertinent documentation.
- Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services).
- If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation.
- PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering or referring provider to ensure medical necessity criteria have been met.
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 Aug 7, 2024