In 2022, Noridian, the Supplemental Medicare Review Contractor (SMRC), published that cataract surgery medical necessity had a 51% error rate.¹ One of the three main errors listed was “insufficient documentation.” Combine this with cataract surgery being one of the most common procedures performed on Medicare beneficiaries, and we have a recipe for continued scrutiny.

The Centers for Medicare & Medicaid Services (CMS) rely on Medicare Administrative Contractors (MACs) to provide guidance on medical necessity documentation requirements within their Local Coverage Determinations (LCD) and Local Coverage Articles (LCA). Currently, there are seven active cataract policies, with WPS Health Solutions being the only MAC without one. Many practices have developed protocols to ensure proper documentation for standard and complex cataract surgery. However, some are missing the nuances associated with obtaining second eye activities of daily living (ADLs) complaints, recording that a tolerable change in eyeglasses will not improve the visual function and co-management.

Considering this, let’s discuss how to keep your documentation on track for passing a potential audit.

ADLs and second eye medical necessity

Most practices have a system in place to gather ADLs by having the patient fill out a visual function questionnaire and/or document any ADLs within the chief complaint. The questionnaire is usually filled out prior to, or at the time of, the cataract evaluation and includes questions specific to ADLs such as issues with driving at night or reading the newspaper. This questionnaire should then be used to drive the chief complaint documentation.

Ensuring that the chief complaint and ADLs match — and are not contradictory — is crucial. It may seem obvious, but the ADLs and chief complaint occasionally conflict. One may establish medical necessity with ADL issues while the other states the patient has “no concerns” or “no issues with their vision.” It is imperative physicians and their clinical team review the chart documentation to ensure both complaints align.

Another issue with ADLs stems from documenting second eye medical necessity. According to Noridian,² a MAC, “the patient and the ophthalmologist should discuss the benefits, risks, need and timing of the second eye surgery when they have had the opportunity to evaluate the results of surgery on the first eye, taking into account the above factors.” One of these listed factors is “visual function of the second eye.”

Practices should examine their documentation protocols and consider implementing a workflow for capturing second eye ADLs at one of the interim postoperative visits. Most practices achieve this by documenting ADLs at the one-week postoperative visit, which would appear to give the patient adequate time to notice a difference between the surgical and nonsurgical eye. Other practices obtain the second eye ADLs with an additional visual function questionnaire completed AFTER the initial surgery.

Referencing the best-corrected visual acuity (BCVA)

As the shortage of surgeons continues, many ophthalmology practices are utilizing optometrists to help keep up with the cataract surgery demand. Often, the patient has their annual comprehensive eye exam with the optometrist, and a referral is placed to the ophthalmologist for possible cataract surgery if warranted.

In these cases, the BCVA is sometimes obtained at the optometrist visit and not repeated at the ophthalmologist visit. According to Palmetto’s LCD,³ “the refraction may be performed by the surgeon or by suitably trained staff in the surgeon’s practice as permitted by law.” If we follow that guidance, the BCVA can be documented by the optometrist within the group practice; however, the ophthalmologist must address the findings within their impression and plan when scheduling surgery.

Many MACs also require verbiage within the plan,⁴ indicating the “visual impairment and function are not correctable by glasses or other non-surgical measures.” By referencing the optometrist’s BCVA with a statement attesting that a tolerable change in eyeglasses will not improve the patient’s visual function, the practice should meet the MAC’s documentation requirements.

Complex cataract surgery

Palmetto, another MAC, addresses complex cataract surgery documentation within their LCA⁵ by stating, “The provider should include complete medical documentation (e.g., operative note) to support the complex cataract extraction as well as a description of the circumstance that justifies the use of the complex cataract extraction code.”

The LCA goes on to give supporting documentation examples such as, “Intraoperative iris hooks were required to address a severely miotic pupil.” Many times, surgeons will indicate that Trypan Blue or a Malyugin ring was used; however, they omit the details indicating why the extra device was needed. Noridian mentions something similar within their Cataract Surgery Policy Checklist⁶ by listing that a “statement supporting justification for requirements of complex cataract surgery” is necessary when submitting additional documentation for complex cataract surgery. Therefore, surgeons must indicate within their operative note what they encountered during the surgery and what extra steps or devices were used to effectively complete the surgery. It may prove beneficial for practices to internally audit all complex cataract surgery operative reports before submitting the claim to ensure that the proper details are documented.

Co-management agreements

First Coast states that “occasionally a physician must transfer the care of the patient during the global care period. In these instances, the use of a modifier will be necessary to distinguish who is providing care for the patient.”⁷

Modifier 54 (surgical care only) and Modifier 55 (postoperative management only) indicate to the payer that a co-management agreement is in place. Although the modifiers help differentiate payment, other documentation requirements are needed when establishing a co-management relationship.

There are two main components to co-management documentation.^8,9 The first is a consent form provided by the ophthalmologist practice and signed by the patient “after being apprised of the medical and/or logistic advisability or the risks and benefits of transfer of care.” Co-management must be patient-directed, and “there should be no routine arrangements between an operating ophthalmologist and non-operating practitioners to automatically share post-operative co-management services, even if the non-operating practitioner originally referred the patient to the operating ophthalmologist.”

Next, a written transfer of care document must be generated and sent to the co-managing optometrist after the surgery. Usually this is done by the surgeon’s scribe or lead technician. The transfer of care document must include the patient’s name, the date of service with the corresponding surgical procedure code(s), and the transfer date indicating when the optometrist is assuming care.

It's imperative for practices to keep documentation standards high and money separate when utilizing co-management. Each respective practice must submit their own claims with the corresponding modifiers to delineate the postoperative care they provided to ensure proper reimbursement. It is against a practice’s best interest to collect for the entire post-operative period and then “cut a check” to the co-managing optometrist for their portion of the care. This could be perceived as violating the Anti-Kickback statute and could result in unwanted scrutiny from various entities. Recently, a practice in Tennessee agreed to pay close to a $17 million settlement to resolve allegations that they violated the False Claims Act and Anti-Kickback statue by financially incentivizing optometrists to refer patients to their clinic.¹⁰

Ultimately, co-management can be a valuable tool for ophthalmic practices when used in accordance with the guidelines and when proper documentation is retained in the patient’s medical record.

As you can see, there are many facets to cataract surgery documentation. It’s crucial for practices to analyze their current processes and revise or establish protocols to ensure proper chart documentation. OP

REFERENCES

1. Noridian Completed Projects 01-302 Cataract Surgery Notification of Medical Review https://noridiansmrc.com/completed-projects/01-302/ Accessed May 25, 2023
2. Noridian Cataract Surgery in Adults LCD https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34203 Accessed May 25, 2025
3. Palmetto Billing and Coding: Complex Cataract Surgery: Appropriate Use and Documentation LCA https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=53047&ver=17 Accessed May 25, 2023
4. Novitas Cataract Extraction (including Complex Cataract Surgery) LCD https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=35091&ver=103 Accessed May 25, 2023
5. Palmetto Billing and Coding: Complex Cataract Surgery: Appropriate Use and Documentation LCA https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=53047&ver=17 Accessed May 25, 2023
6. Noridian Cataract Surgery Policy Checklist https://med.noridianmedicare.com/documents/10546/27061036/Clinician+Checklists+Cataract+Surgery Accessed May 25, 2023
7. First Coast Post-Operative Co-Management Fact Sheet https://medicare.fcso.com/Fee_resources/0487996.asp Accessed May 25, 2023
8. https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00101754
9. Novitas Post-Operative Co-Management Fact Sheet https://www.palmettogba.com/palmetto/jjb.nsf/DIDC/B9LP5Q2515~Specialties~Optometry%20and%20Ophthalmology Accessed May 25, 2023
10. SouthEast Eye Specialists Pays $17 million to Settle Anti-Kickback, False Claims Allegations https://www.prnewswire.com/news-releases/southeast-eye-specialists-pays-17-million-to-settle-anti-kickback-false-claims-act-allegations-301812112.html Accessed May 25, 2023

Brittney Irwin, COT, CPC-A, CEP, is an associate consultant within the Billing, Coding and Compliance Division of BSM Consulting. In her role, she provides ongoing billing and coding support to ensure ophthalmic regulatory compliance. Previously, she spent more than 10 years working in ophthalmology, most recently as the clinical director of a multi-specialty group.