Medicare Compliance & Reimbursement

Tip: Beef up chart notes with knowledge of 5 critical items.

Because cataract surgery continues to be one of the most commonly performed surgeries, it remains a top audit target for all payers. If your practice performs cataract surgery, it may only be a matter of time before you get audited.

You can start preparing for this eventuality by reviewing your payer policies for specific documentation requirements and taking steps to make sure your medical records stand up to scrutiny. Minimize errors and omissions by reviewing the following rules and requirements and incorporating them into your cataract surgery pre-op workup checklist.

Know the Medical Necessity Rules

The Centers for Medicare & Medicaid Services (CMS) — and payers that follow Medicare guidelines — will cover the costs of medically necessary cataract surgery. For example, Palmetto GBA, a Medicare Part B carrier, considers lens extraction medically necessary and covered when one or more of these conditions exist:

• Cataract causing symptomatic impairment of visual function not correctable with a tolerable change in glasses or contact lenses, lighting, or nonoperative means resulting in specific activity limitations and/or partici­pation restrictions including, but not limited to reading, viewing television, driving, or meeting vocational or recreational needs;
• Concomitant intraocular disease (e.g., diabetic retinopathy or intraocular tumor) requiring monitoring or treatment that is prevented by the presence of cataract;
• Lens-induced disease threatening vision or ocular health;
• High probability of accelerating cataract development as a result of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments such as external beam irradiation;
• Cataract interfering with the performance of vitreoretinal surgery; and/or
• Intolerable anisometropia or aniseikonia, uncorrectable with glasses or contact lenses, exists as a result of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity).

Medicare will consider covering other conditions, as well, but you’ll need documentation that supports medical necessity and is compatible with the accepted standards of medical care. So, you should seek coverage for those on a case-by-case basis by working with your payers.

Watch for this: Surgery is not deemed to be medically necessary purely on the basis of lens opacity in the absence of symptoms. Also, the Snellen visual acuity chart results should be documented and will be considered toward medical necessity — but they’re not enough on their own.

“An evaluation of visual acuity alone can neither rule in nor rule out the need for surgery,” Palmetto says in its Local Coverage Determination (LCD). “Visual acuity should be recorded and considered in the context of the patient’s visual impairment and other ocular findings.”

Now that you’re familiar with medical necessity requirements, let’s take a closer look at five criteria for cataract surgery.

1. Lifestyle Complaint Indicating Hindrance of ADLs

Providers must ask patients about their visual symptoms and the activities they have difficulty performing to help establish the need for cataract surgery. Documentation of a chief complaint that impacts an activity of daily living (ADL) — reading, viewing television, driving, or meeting vocational or recreational expectations — is a fundamental requirement for all payers, notes Joy Woodke, COE, OCS, OCSR, director of coding and reimbursement at the American Academy of Ophthalmology. Try to include the patient’s own words in the note, where possible, and specify the eye(s) impacted.

Tip: Ensure the medical record describes specific symptomatic impairments of visual function resulting in specific activity limitations.

Check individual payer policies for specific documentation requirements related to patient symptoms. For example, do patient complaints recorded in the chart note suffice, or is the use of a patient questionnaire (e.g., VF-8R) form required?

2. Objective Evidence of Cataract

Most payers require a preoperative comprehensive ophthalmologic exam (or its equivalent components occurring over a series of visits). Ophthalmologists should perform and document all 12 eye exam elements, the degree of lens opacity, and the type and grade of cataract (i.e., 1-4+). Make sure they consider and document the status of any concomitant ocular diseases that are present that could possibly affect the patient’s vision.

Tip: Have your providers include a statement in the medical record that they believe the cataract is significantly contributing to the patient’s visual impairment.

3. Reduced Visual Acuity

Most policies want documentation of best-corrected visual acuity (BCVA), which requires a refraction. Patients may also need to undergo near vision and glare testing, both with uncorrected VA and BCVA, when indicated by the chief complaint. When they do, best practice is to document the method of glare testing.

“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,” notes Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

Glasses aren’t an option: An indication that surgery may be necessary is when the patient’s vision cannot be improved with a tolerable change in eyeglasses. So, you should include a statement by the surgeon in the documentation confirming that a change in glasses or contacts does not provide satisfactory functioning vision and the patient’s lifestyle is compromised. Many payers require such a statement.

4. Good Prognosis for Improvement

Often, 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 attestation 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.

5. Informed Consent and Anesthesia

In addition to a cataract diagnosis, recommendation for surgery, and attestation that there’s a reasonable expectation that surgery will improve visual function, payers also expect documentation that the patient has been educated by the surgeon about the risks, benefits, and alternatives to cataract surgery, has provided consent, and desires to proceed with the operation. It’s also important to note that the patient can tolerate anesthesia, and their awareness is sufficient to provide informed consent for surgery.

Prioritize Making Your Charts Audit-Proof

Over the past few years, ophthalmic practices around the country have received notification of Targeted Probe and Educate (TPE) audits and Supplemental Medicare Review Contractor (SMRC) audits focused on claims for cataract surgery (see story, p. 7). “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 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,” advises Johnson.

Note that while Medicare policies include many of the same elements, some provide more restrictive instructions on how the information needs to be documented.

Tip: Instead of trying to keep up with the different guidelines set forth by various payers, implement a single protocol for all payers — consider employing a procedure that meets the criteria outlined in your most restrictive policy to help ensure your charts can withstand payer scrutiny.

Lastly, ensure you’re in compliance by performing internal chart audits.

Resources: Check out Noridian Medicare’s Cataract Surgery Policy Checklist at https://med.noridianmedicare.com/documents/10546/27061036/Clinician+Checklists+Cataract+Surgery. Review CMS guidance on documentation and coding at >www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57196&ver=17.