Ophthalmology and Optometry Coding Alert

Compliance:

Focus on Cataract Surgery Billing Best Practices

Published on Tue Nov 21, 2023

Learn what three things are most apt to attract an auditor’s attention.

Because cataracts continue to be one of the eye conditions for which Medicare pays most often, they have been, and remain, a top audit target. Investigations have revealed vulnerabilities, and to rein in improper payments for cataract-related services, the Center for Medicare and Medicaid Services (CMS) has increased efforts to identify and contain compliance infringements.

Last month, we provided pointers to help you better understand the criteria for medical necessity and documentation and coding practices that’ll help audit-proof your claims. In this article, we’ll focus on proper management and compliant cataract billing. Read on for a few more tips on how you can mitigate risk and protect your practice’s bottom line.

Put These High-Risk Areas on Your Radar

Coding for cataract surgery is typically straightforward, so why have there been multiple investigations into improper billing and co-management of cataract surgical procedures? It’s because cataract surgery is heavy in its nuances outside of coding. To minimize red flags that can draw an auditor’s attention, you must recognize the biggest compliance risks and employ best practices in everything from documentation to education of all staff, as well as patients.

The first tip for staying off an auditor’s radar: Do not bill for removing more than one cataract from the same eye. While this may sound obvious, thanks to human error, some practices have done exactly that. How? By submitting the wrong CPT^® modifier or ICD-10 code when billing the second cataract surgery. Tip number two: avoid overutilization of the code for complex cataract surgery by knowing what constitutes complex and understanding the difference between complexity and complications.

However, one of the biggest compliance risks surrounds misunderstanding the intricacies of billing for presbyopia-correcting (PC) and astigmatism-correcting (AC) intraocular lenses (IOLs). As you may recall, a standard cataract surgery is covered by payers with the patient owing only a co-pay and/or deductible. But there are lens upgrades the patient can choose for enhanced vision outcomes that are not covered. These upgrades must be paid out of pocket — and this is where education and documentation come into play.

Prioritize Educating Staff on Premium IOLs

Stave off problems by educating your staff on what different care packages contain. They must understand the various IOL and surgical options and how to explain them. This will enable proper patient education concerning upgraded lens choices.

“I typically use an analogy when explaining this situation while working with teams. I relate coverage to shoes because, well, shoes are wonderful. Payers pay for standard, no-name shoes. There is nothing wrong with those shoes — they function well. But as a consumer, I like more comfortable and/ or stylish shoes. I believe I should be able to live my life in Jimmy Choo shoes. I don’t want regular shoes. But if I want the Jimmy Choo shoes, I need to pay extra for the Jimmy Choo experience. That is how payers relate to the upgraded lenses. If I want vision enhancement as a patient, I need to pay for the upgrade,” explains Rhonda Buckholtz, CPC, CDEO, CPMA, CRC, CENTC, CGSC, COBGC, COPC, CPEDC, AAPC Approved Instructor, owner of Coding and Reimbursement Experts in Annapolis, Maryland.

This means you should “take care to document the patient’s lens choice, understanding of financial responsibility for the upgrade, and informed consent,” adds Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

Keep in mind: You cannot charge for the use of sophisticated technology. You can only charge for vision outcomes. Payers don’t care if you use state-of-the-art equipment. Coverage and reimbursement for standard cataract surgery do not change based on the instruments used — it is the same whether a cystotome or femtosecond (FS) laser makes the capsulotomy.

Without proper training, staff might erroneously explain that a charge was for the laser, when really it was for the correction of astigmatism. An uneducated team can put a practice at increased legal risk.

Take Steps To Reduce Compliance Risk

Here are some best practices for reducing your risk when performing cataract surgery and the services leading up to them, according to Buckholtz:

Co-management: All patients should choose whether they want their surgery to be co-managed. Never automatically send them back to the referring optometry doctor (OD).
o Have the patient sign a consent acknowledging their desire to have their post-op care performed by the referring OD. “The surgeon can always override that request if it is not clinically appropriate,” notes Johnson.
o Make sure your provider documents that it is safe to return the patient to the OD.
o If your OD refers a patient to a cataract surgeon, then make sure to document that the patient was given choices of whom to go to; don’t send all your referrals to the surgeon that treats your practice the best. All patients deserve a choice.
Lens choices: Many surgeons offer various packages outside of the standard lens covered by payers.
o Document the patient’s education regarding the types of services offered and the potential outcomes for each.
o Make sure the patient knows exactly how much they will pay out of pocket.
o Set charges based on the services needed to achieve the desired visual outcome. Never charge solely for technology.
ABNs: You do not need to have a patient sign an Advance Beneficiary Notice (ABN) of Noncoverage form (CMS-R-131) for upgraded lenses and treatment of astigmatism. However, it is recommended that you document their understanding and acceptance of financial responsibility.
Education: This is key: Educate, educate, educate. An informed patient is a happy patient. An informed staff member can answer patient questions, which keeps the patient happy. Provide education on cataracts in this way:
o Have a surgeon explain to coders each treatment and how they differ.
o Educate staff about the various options, including Medicare and other payers’ coverage.
o Educate the patient every step of the way. Remember to empathize. What is routine to you is the first time for the patient. Make sure your processes are well documented at each step.
Policies: Develop robust policies and procedures and put them into action.
Complaints: Log all patient complaints. This will give you a good way to monitor whether training is well-understood and effective. Address new concerns as they pop up.
Follow-up: Utilize a secret shopper to ask your staff cataract questions. Document responses and use them for future training, if necessary.
Audits: Audit medical record documentation and policies periodically to uncover issues of noncompliance.