Ophthalmology and Optometry Coding Alert

Question: We had a patient present because her son told her that her eyes are “cloudy.” Although the physician noted lens opacity, he did not deem her condition payable for cataract excision. The patient was displeased with this news and argued that her condition should be treatable. What can we say?

Utah Subscriber

Answer: You should show the patient the local coverage determination from her Part B MAC to demonstrate that the condition isn’t payable. Noridian Medicare, the Medicare carrier in Utah, states in its cataract excision policy, “Surgery is not deemed to be medically necessary purely on the basis of lens opacity in the absence of symptoms.”

If the patient does ask what makes the service payable, you can share the following from Noridian’s policy:

1. Cataract causing symptomatic (i.e. causing the patient to seek medical attention) impairment of visual function not correctable with a tolerable change in glasses or contact lenses resulting the patient’s inability to function satisfactorily while performing activities of daily life 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 (including, but not limited to, phacomorphic or phacolytic glaucoma).

4. High probability of accelerating cataract development as a result of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocycleotomy, procedure for ocular trauma) and treatments such as external beam irradiation.

5. Cataract interfering with the performance of vitreoretinal surgery.

6. Intolerable anisometropia or aniseikonia uncorrectable with glasses or contact lenses that exists as a result of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity).

If the patient would like to proceed with cataract surgery despite the non-coverage conditions for her situation, you can advise her what the cost would be to do the surgery electively and ask her to sign an advance beneficiary notice (ABN).