As the most frequently performed ophthalmic surgeries, cataract procedures continue to receive payer scrutiny. Between the Targeted Probe and Educate audits,¹ the 2022 Supplemental Medicare Review Contractor (SMRC) audit conducted by Noridian,² the 2022 Medicare Fee-for-Service Supplemental Improper payment data,³ and attention from non-Medicare payers, many cataract surgeons are reviewing their charts and claims and, where necessary, making changes to strengthen the notes. 

During the patient’s cataract exam or consultation, the surgeon determines the medical necessity for cataract surgery based on the exam findings and the patient’s desire for surgery. Insurance payers, including Medicare, provide their own requirements for medical necessity to support reimbursement of claims for cataract surgery. 

Before scheduling surgery, providers are encouraged to confirm that both the clinical need for surgery and the payer’s requirements for payment are met and documented. 

Practice staff also play an important role in preparing appropriate medical records and correct claims. Here is a summary of how to establish and document the need for cataract surgery.

Understand coverage guidelines

One of the most basic requirements for surgery is a subjective comment from the patient regarding their visual limitations caused by the cataract. How this is obtained and documented can be payer specific; either as part of the patient interview (chief complaint [CC] and history of present illness) or on a unique patient questionnaire. 

Beyond this, review payer policies for best-corrected Snellen acuity requirements, instructions for manifest refractions and glare testing, and consideration of ocular comorbidities and their impact on the patient’s visual limitations. 

Document medical necessity

Creating an internal protocol helps with consistency in the patient workup and surgery scheduling process by organizing your patient history and exam notes. Attempting to write protocols to match each policy is impractical; there are too many and they change too frequently. 

Consider your contracts with the most restrictive policies and establish a single internal approach that meets those criteria. For Medicare Part B, the current policy by Noridian Medicare, the current SMRC is a useful example. 

A summary of required elements from the Noridian policies includes:

• Patient’s inability to function satisfactorily (activities of daily living, or ADLs)

• Best-corrected visual acuity (BCVA) by careful
refraction

• Degree of lens opacity

• Physician attestation eyeglasses/contact lenses won’t help

• With other comorbidities, cataract is significantly contributing to visual impairment

• Patient desires surgery, and surgeon expects it to
improve visual and functional status.

Although most patients undergo cataract surgery on both eyes within a short period of time, it is not a forgone conclusion. The surgeon and patient are expected to finalize that decision after the first surgery takes place. Timing of the second surgery is contingent on:

• The patient’s visual needs

• The patient’s preferences

• Visual function in the second eye

• The medical and refractive stability of the first eye

• The need to restore binocular vision and resolve anisometropia

• An adequate interval of time has elapsed to evaluate and treat early postoperative complications in first eye, such as endophthalmitis; and/or

• Logistical and travel considerations of the patient.

Document patient complaints, work up, and exam

The patient’s lifestyle complaint is often obtained as part of the intake interview and can be recorded with a visual function patient questionnaire such as the VF-8 or VF-14. Document specific examples of visual problems or limitations due to decreased vision including difficulty driving, working, reading or perhaps other activities such as hobbies or problems caring for themself. Payers are not impressed with vague, generic comments, like “vision affects ADLs”, that do not provide unique information about each patient.

The elements of the patient work up and physician exam change based on the patient’s complaint. For example, a complaint of trouble reading should be accompanied by a refraction at near. Complaints of glare or halos around lights, TVs or computer screens should be accompanied by a glare test to demonstrate the effect of the glare on the patient’s acuity. 

Thorough charting is critical. Make it easy by working with a checklist. Use information from the patient’s complaint and history, the technician’s work up, and the physician’s exam findings to complete the check list. Some key elements include:

• The CC and ADLs voiced by the patient

• BCVA

• Properly executed brightness acuity test or glare test, when appropriate

• Presence and description (grading) of cataract noted on slit-lamp exam

• Physician’s attestation that a tolerable change in eyeglasses or contact lenses will not meet    the patient’s needs

• Physician’s attestation that the cataracts are contributing to the visual status and the expectation that cataract surgery will improve functional vision 

• Patient’s attestation that they wish to proceed with surgery

• Informed consent

• Discussion of out-of-pocket cost for non-covered, premium, or refractive services. 

Ophthalmic personnel play a key role

The role of ophthalmic assistants and technicians varies from practice to practice, but some constants should apply to most offices. Well-trained, attentive staff bring value to the practice by improving patient flow, assisting the physician in providing excellent care, and enhancing the patient experience. 

This starts with a concise but thorough history. Patients appreciate an efficient interview without a lot of repetition and duplicate forms to complete. On the other hand, the information available to the surgeon and facility must be thorough, accurate, and up to date. Patients scheduled for cataract surgery undergo preoperative testing and often require outside testing or history and physical, or H&Ps. 

Technicians should be involved when establishing or revising your patient workflow. Also, cross-training ophthalmic assistants and technicians in various tasks in the workup process helps ensure continuity even if staff changes. OP

REFERENCES:

1. Novitas. Targeted Probe and Educate (TPE) round results. https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00261705. Accessed March 15, 2024.

2. Noridian Healthcare Solutions. Noridian Completed Projects 01-302 Cataract Surgery Notification of Medical Review Noridian Completed Projects 01-302 Cataract Surgery Notification of Medical Review. https://noridiansmrc.com/completed-projects/01-302/ Accessed March 15, 2024.

3. Three Reasons Why Cataract Practices Failed SMRC Audits—and Three Solutions. https://www.aao.org/eyenet/article/why-cataract-practices-failed-smrc-audits. Accessed March 15, 2024.

Mary Pat Johnson, COMT, CPC, COE, CPMA is a Certified Professional Medical Auditor and a Certified Professional Coder by the American Academy of Professional Coders. She has also obtained the Certified Ophthalmic Executive (COE) designation. Ms. Johnson conducts business from the Corcoran Consulting Group’s North Carolina office.