A review of the key documentation requirements associated with cataract surgery

Before you skip this article, presuming it is just another reminder to document patients’ activities of daily living (ADLs) prior to surgery, bear with me. With the recent uptick in audit activity related to cataract surgery, now is a good time to review your payer policies for the specific documentation requirements that go beyond limitations to the patients’ ADLs.

Audit activity and attention by payers

In recent months, ophthalmic practices around the country have received notification of Targeted Probe and Educate audits and Supplemental Medicare Review Contractors audits focused on claims for cataract surgery. More recently, CMS began sending Comparative Billing Reports focused on cataract-related services. In responding to these requests, pay close attention to the instructions in the Local Coverage Determination (LCD) for your Medicare Contractor. Review and adhere to the items noted in the Indications for Coverage section as well as the Documentation Requirements section of your policy.

Criteria for cataract surgery

The American Academy of Ophthalmology’s Preferred Practice Patterns for Cataract Surgery in the Adult Eye¹ lists the criteria for cataract surgery, including:

• Objective evidence of a cataract
• Reduced visual acuity
• Lifestyle complaints that indicate hindrance of activities of daily living
• Good prognosis for improvement
• Patient can tolerate anesthesia
• Patient awareness sufficient to provide an informed consent for surgery
• Much less frequently, cataract removal is performed to permit treatment of retinal pathology or glaucoma induced by the lens.

Most Medicare policies include many of the same elements, but some provide more restrictive instructions on how the information is documented.

Patient symptoms (ADLs)

Watch payer polices for specific documentation requirements related to patient symptoms. For example, do patient complaints recorded in chief complaint and patient interview suffice, or is the use of a patient questionnaire (eg, VF-8R) form required?

Best-corrected acuity

While a specific Snellen acuity may not be noted, most policies require that best corrected vision be documented. This requires a refraction. Some payers may allow an auto-refraction while others will require a manifest refraction. Likewise, some allow surgeons to use a recent refraction provided in incoming records from a referring doctor, while others require the refraction be done in the surgeon’s office.^2,3

Surgery may be indicated if the patient’s vision cannot be improved with a tolerable change in eyeglasses. A statement by the surgeon confirming that a change in eyeglasses won’t alleviate the visual symptom is required by some carriers.

Comorbidities

Many patients present with multiple ocular conditions that affect the patient’s vision. Cataract surgery is warranted when other ocular diagnoses have been ruled out as the source of the decreased vision. A physician’s attestation³ should indicate that the cataract is believed to be significantly contributing to the patient’s visual impairment and that lens surgery will significantly improve both the visual and functional status of the patient.

Planning surgery in the fellow eye

Many patients undergo cataract surgery on both eyes over a short period of time. Chart documentation must include separate documentation to support the medical necessity of each case.

Complex cataract surgery

The CPT definition of complex cataract surgery procedure (CPT 66982) requires “devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for IOL or primary posterior capsulorrhexis.”

The use of trypan blue dye is not mentioned in this CPT definition. A 2016 CPT Assistant publication⁴ states the use of dye by itself “does not reach the threshold of physician time, work or intensity necessary to report the complex cataract code.” Some LCDs disagree.^5-9

Combination procedures

In recent years, CPT introduced four new codes to describe procedures that include cataract surgery and a glaucoma procedure. CPT 66987 and 66988 involve endoscopic cyclophotocoagulation procedures, while codes 66989 and 66991 include aqueous drainage devices.

When reporting these codes, medical necessity for each procedure must be clear. Ensure that the documentation supports the criteria for the glaucoma portion of the case as well as the criteria for the cataract portion.

Conclusion

Your Medicare policy may not match what is required by Medicare Advantage Plans and/or commercial payers, so be sure to review them carefully.

To understand and follow different guidelines for different patients is nearly impossible. A single protocol for all payers is much easier to administer. Consider implementing a procedure that meets the criteria outlined in your most restrictive policy to help ensure your charts can withstand scrutiny from a payer. OP

REFERENCES:

1. American Academy of Ophthalmology. Cataract in the Adult Eye PPP 2021. https://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp-2021-in-press . Accessed October 7, 2022.
2. Centers for Medicare and Medicaid Services. Palmetto LCD. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=34413&ver=51 . Accessed October 7, 2022.
3. Centers for Medicare and Medicaid Services. Noridian LCD. https://go.cms.gov/3T8uqzi . Accessed October 7, 2022.
4. The CPT Assistant. Volume 26, Issue 3, March 2016.
5. Centers for Medicare and Medicaid Services. Palmetto GBA. https://go.cms.gov/3yA1oRf . Accessed October 7, 2022.
6. Centers for Medicare and Medicaid Services. National Government Services (NGS). https://go.cms.gov/3yAcWnh . Accessed October 7, 2022.
7. Centers for Medicare and Medicaid Services. Noridian Healthcare Solutions. https://go.cms.gov/3COIhVQ . Accessed October 7, 2022.
8. Centers for Medicare and Medicaid Services. Novitas Solutions. https://go.cms.gov/3g2VBgk . Accessed October 7, 2022.
9. Centers for Medicare and Medicaid Services. First Coast Service Options. https://go.cms.gov/3g3Syop . Accessed October 7, 2022.