Ophthalmology and Optometry Coding Alert

Answer: You should share the Medicare coverage guidelines with the patient and let her know that her cataracts don’t meet the reimbursement criteria for the surgery. Therefore, if she chooses to proceed with surgery, ask her to sign an advanced beneficiary notice (ABN) and explain to her that she is likely to be responsible for paying you for the procedure. In addition, let her know the medical reasons precluding the condition from meeting Medicare’s guidelines.

Background: 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 in 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.”

Sharing this information with her might make it clear that although she is experiencing opacity from the cataracts, the physician’s clinical evaluation of her condition has to go beyond that to meet the payment criteria.