New CMS audits focus on specifics in coverage documents.

Recently, I’ve heard of Medicare auditors who are very strictly applying their coverage documentation requirements related to cataract/intraocular lens surgery.

One Medicare contractor in California randomly selected a busy surgeon for a review of charts to see if they fully supported the later claim for cataract surgery. Unfortunately, this client was unable to convince the auditor (first via the chart review, then later in a requested phone call) that their documentation was sufficient. Since it was not, the office will have to refund the surgeon fee for their reviewed 66984 and 66982 claims. (This may also end up costing the ASC if that entity solely relied on those notes to support their claims.)

This also calls into question the other “non-audited” charts, which is perhaps a larger issue; this office is now “on notice” and is obligated to check them and see if they made similar mistakes. I saw some of the charts for myself, which were not altogether bad. But, in the end, I agreed that the payer’s requirements were very clearly spelled out and the office’s charts weren’t adequate.

This client isn’t likely to make these mistakes again. Though they are somewhat understandable in our “post-COVID world” where we may be working short-handed and trying to be more efficient, it is worth taking the time to get the charts right due to the potentially devastating effects on a practice’s finances.

Ensuring coverage

In this case, the Medicare Part B policy for cataract surgery is in two documents: the Local Coverage Article¹ (LCA) and the Local Coverage Determination (LCD).² Most LCAs have the list of covered ICD-10 diagnoses for a service, while the LCDs have the rest of the information needed to ensure they’re following coverage guidelines. Both documents are important to check on a regular basis, ideally before a new patient procedure, although changes are rarely made.

When you are looking to document support for a claim — in addition to having a covered diagnosis — you want to know these things from the payer:

• Under what circumstances the service is covered
• Whether there are any limitations to coverage (when there is no or only limited coverage)
• Documentation requirements (be on the lookout for the terms “must” or “shall” so you know what cannot be missing)

Where the charts went wrong

Under “Documentation Requirements,” this particular LCD states, “The following documentation must be present in the medical chart” then lists six absolute requirements.

For this office, here were the two main issues they had missed and the piece of the “must” language they violated:

1. The charts did not always have a best-corrected acuity. “A best-corrected Snellen visual acuity at distance (and near if the primary visual impairment is at near) as determined by a careful refraction under standard testing conditions as appropriate must be recorded to establish the inability to correct the patient’s visual function with a tolerable change to glasses or contact lenses. Neither uncorrected visual acuity nor corrected acuity with the patient’s current prescription will satisfy this requirement. The refraction may be performed by the surgeon or by suitably trained staff in the surgeon’s practice as permitted by law.” Sometimes the office had only a pinhole vision over current glasses, while in other charts they had an auto- or manifest refraction done but no recorded vision. Glare verification (if it is needed at all) should be done with the best correction in place. In the interest of speed they might have skipped a best-corrected acuity, but the contractor essentially is saying “Don’t do that if you want to keep your money.”
2. The office did not have a specific attestation that the visual function loss due to cataract could not be improved by changing glasses. The Medicare Administrative Contractor (MAC) states, “An attestation supported by documented symptoms and physical findings in the medical record indicating that the patient’s impairment of visual function is believed not to be correctable with a tolerable change in glasses or contact lenses.” This was often missing as they thought anyone could discern it from reading the chart. But the MAC is very specific, so leaving it out is a violation of the coverage they mandate to ensure payment is made and can be kept.

In this example, the MAC makes other demands to support the claim, but the office was generally OK on those. Importantly, these “must” requirements aren’t like a grade in school where 90% means an “A.” Here, the chart still fails.

Summary

When very specific language appears in a coverage document, be sure and follow it to a “T.” This also means periodically checking for updates and revisions for both Medicare and private payers. Make changes as appropriate to your documentation (eg, EMR smart phrases) so you can better protect your claims.

And as always, “good coding to you.” OP

REFERENCES:

1. Noridian. Local Coverage Article #A57195. Revision Effective Date: 1/01/22. Billing and Coding: Cataract Surgery in Adults. https://tinyurl.com/3tdv89j2 . Accessed May 12, 2022.
2. Noridian. Local Coverage Determination #L34203. Revision Effective Date: 10/01/19. Cataract Surgery in Adults. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=34203&ver=16 . Accessed May 12, 2022.