Ophthalmology and Optometry Coding Alert

Plus: Know how to spot documentation flaws that could land you in hot water.

During the past few years, ophthalmologists have been inundated with news announcements about nationwide audits of cataract claims, and it looks like some of those reviews are leading to a few unpleasant discoveries.

Case in point: In early January, Arizona Attorney General Mark Brnovich announced the indictment of an ophthalmologist in the state who was charged with conspiracy, fraudulent schemes, illegal control of an enterprise, and theft for allegedly defrauding Medicare and other payers.

During a nine-year period, the physician was said to have directed scores of staff members to document fraudulent eye exams that would justify cataract and laser surgeries. “The false information was calibrated in such fashion to satisfy the standards of third-party insurers, public and private, for cataract or laser surgery coverage,” Brnovich said in a press release about the case. “It is alleged fraudulent exam documents were maintained in patient records in the event of scrutiny or oversight via prospective audits related to the legitimacy or necessity of payments … for cataract or laser surgery. It is possible that some patients had cataract surgeries that were not medically necessary.”

To ensure that you don’t find your practice in hot water for these types of issues, consider the following documentation best practices, and if you see anything in the notes that looks amiss, don’t hesitate to follow up to ensure that the documentation is genuine and accurate.

Know the Ideal Cataract Documentation

The patient’s medical record must include specific documentation that justifies the medical necessity for the cataract procedure that you are performing. For a visually symptomatic cataract, for instance, the record should contain:

A statement that describes specific symptomatic impairment of visual function resulting in specific activity limitations.

The patient’s own words describing their condition. For instance, “My right eye is so foggy I can’t even read street signs, but my left eye is clear.” This type of patient-specific comment shows the individuality of each patient record.

A statement or measurement showing that the patient’s visual impairment is not correctable with a tolerable change in glasses or contacts. Past exam findings included here would be helpful if the deficit has changed.

A best-corrected Snellen visual acuity at distance under standard testing conditions. Whereas neither uncorrected nor corrected visual acuity with the patient’s current prescription will satisfy this requirement, the refraction must be performed by the surgeon or suitably trained staff members. When cataract is the primary cause of impairment, the degree of lens opacity should correlate with the impairment.

If there are coexisting ocular diseases, the medical record should indicate that the cataract is the primary cause of visual compromise.

A statement that the patient desires surgical correction, and that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that lens surgery will significantly improve both the visual and functional status of the patient. Again, this makes the documen­tation patient-specific and shows how the condition affects them personally.

Know the Medical Necessity Rules

Medicare and payers that follow Medicare guidelines will cover the costs of medically necessary cataract surgery. For example, in its local coverage determination (LCD), Part B MAC Palmetto GBA considers lens extraction medically necessary (and covered by Medicare) when one or more of these conditions exists:

1. Cataract causing symptomatic impairment of visual function not correctable with a tolerable change in glasses or contact lenses, lighting, or non-operative 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.

2. Concomitant intraocular disease (e.g., diabetic retinopathy, or intraocular tumor) requiring monitoring or treatment that is prevented by the presence of cataract.

3. Lens-induced disease threatening vision or ocular health.

4. High probability of accelerating cataract development as a result of a concomitant or subsequent procedure and treatments such as external beam irradiation.

5. Cataract interfering with the performance of vitreoretinal surgery.

6. Intolerable anisometropia (two eyes having significant differences in refractive power) or aniseikonia (a significant difference in the perceived size of images) 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 typically consider any conditions not covered in the above items on the standard of care and other factors related to medical necessity.

Watch for: Your ophthalmic surgeon should not base their decision on lens opacity alone. “Surgery is not deemed to be medically necessary purely on the basis of lens opacity in the absence of symptoms,” says Palmetto.

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, Palmetto says.

“Testing only with high-contrast letters viewed in dark room conditions will underestimate the functional impairments caused by some cataracts in common real-life situations,” the LCD says. “While a single arbitrary objective measurement might be desirable, a single Snellen visual acuity alone can neither rule in nor rule out the need for surgery.”

More Specificity Means Avoiding “Unspecified” Diagnosis

The ICD-10 diagnosis codes for cataracts — those that will support medical necessity — are within the H25.011- H25.89 range for age-related cataracts and the H26.001- H26.8 range for other cataracts.

Most of these codes have six characters, which specify details such as the kind of cataract and which eye is affected. With all the documentation requirements for billing, there should be no need for the “unspecified” cataract codes H25.9 and H26.9.

66982-66984 Are Common CPT^® Codes — But Watch for Audits

The most common CPT^® codes for cataract surgery are:

• 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation)
• 66983 (Intracapsular cataract extraction with insertion of intraocular lens prostheses (1 stage procedure))
• 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation)

Watch for: Don’t report 66982 just because the ophthalmologist encountered a surgical complication, such as the need to perform a vitrectomy. However, keep a close eye on the operative note. This is the documentation that will substantiate the complex cataract surgery.

Second eye: If a symptomatic cataract is present in both eyes, the surgeon will generally only perform the surgery on the first eye because of the potential for vision loss in both eyes. More commonly, the second cataract will be addressed after an appropriate interval.

Don’t Forget PC or ACIOL Extras

Every cataract procedure includes the insertion of an intraocular lens (IOL) prosthesis. If the procedure is performed in a facility setting, you would not be able to code separately for the lens supply. However, in an office setting, Medicare allows you to report V2632 (Posterior chamber intraocular lens) for a conventional IOL.

If the patient receives IOLs that correct presbyopia or astigmatism, Medicare will still only pay the cost of a standard IOL; the patient will be responsible for the extra cost for the presbyopia or astigmatism correction.

You can code this extra portion with HCPCS Level II code V2787 (Astigmatism correcting function of intraocular lens) for an astigmatism-correcting IOL (ACIOL). Code the extra cost of a presbyopia-correcting IOL (PCIOL) with V2788 (Presbyopia correcting function of intraocular lens).

Medicare will not pay the extra cost, so the responsibility for payment for V2787 or V2788 will ultimately fall to the patient.

Rationale: “A single PCIOL or ACIOL essentially provides what is otherwise achieved by two separate items: an implantable conventional IOL (one that is not presbyopia- or astigmatism-correcting), and refractive correction similar to the correction provided by refractive surgery, eyeglasses or contact lenses,” CMS says in its “Medicare Vision Services” document.

Reporting V2787 or V2788 to Medicare is optional. The patient may ask you to do so in order to receive a denial that they can then submit to a secondary payer to receive payment. In that case, append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit) to the V code.