Proving Medical Necessity for Cataract Surgery Crucial to Reimbursement
Published on Fri Oct 01, 1999
There was a time when an ophthalmology practice would get paid for cataract surgery, no questions asked. Now some commercial insurance companies are requiring extensive documentation before granting precertification for such procedures. And Medicare carriers want to make sure there is medical necessity for these procedures as well.
There are two or three main criteria that payers look at for medical necessity: the history, a vision test, and, sometimes, a glare test. But the most important is history.
Why History is Key
The technician or physician must ask every patient whether there are any visual problems interfering with their lifestyle, explains Theresa Collins, insurance supervisor for Suncoast Eye Center in Hudson, FL.
Basic questions should cover whether there is any difficulty with reading, driving, driving at night, seeing something far away, seeing something close up, doing fine tasks such as threading a needle, and more, says Collins. The answers to these questions can substantiate medical necessity for cataract surgery, so its important for the technician to do a thorough interview. The patient must have a complaint that the vision problem is impairing his or her daily living activities in some way regardless of how bad the best corrected visual acuity is.
A history questionnaire may sound easy, but this isnt as straightforward as you think. (For an example of a patient questionnaire, please see box on page 74.) There are subtle psychological influences at work here. A lot of patients dont want to admit that theyre having a problem seeing, notes Jane Walls, surgery scheduler for the North Iowa Eye Clinic in Mason City, IA. Many patients are retired, and they really dont want to say they are having problems driving. They need to get from point A to point Bits their life. Some patients have even stopped driving because they know they cant see well enough, but they still want to keep their license, and for that reasonas well as for vanity reasonswill not confess to having problems. This takes some sensitivity on the part of the technician.
Sometimes you have to reword the question, says Walls. You dont want to sound too threatening. One way is to tell them that youre not going to report them to the Department of Transportation.
Another important message to get across is that the problemwhatever it is doesnt have to be suffered in silence. There can be a treatmentsuch as cataract surgery if the problem is a cataract. You can explain its okay to have this problem, because it can be fixed, Walls adds.
What really brings many of these reluctant patients in is failing the vision part of the drivers license renewal test, she continues. In many cases, [...]
