Wiki Cataract Surgery- Refraction in Documentation

[mmfaust]

Our organization was recently audited by CMS and our documentation was found to not meet medical necessity. According to the CMS LCD, it is stated that a refraction needs to be performed to determine visual acuity. Can we use the optometrist refraction from the referral to satisfy this requirement? And if so, would one year be a reasonable time frame to use? Or is the surgeon’s office required to perform a refraction for every cataract patient?

 

[Cheezum51]

I would request that your referring OD send you the most recent refraction and, as part of the pre surgery exam by your doctor, have your techs work from that to see if they find any refractive changes and document that refractive result and acuities in the record.

IMHO, one year is not a reasonable amount of time since the last refraction. You need to have more up to date refractive data than that.

Tom Cheezum, OD, CPC, COPC

 

[mmfaust]

I would request that your referring OD send you the most recent refraction and, as part of the pre surgery exam by your doctor, have your techs work from that to see if they find any refractive changes and document that refractive result and acuities in the record.

IMHO, one year is not a reasonable amount of time since the last refraction. You need to have more up to date refractive data than that.

Tom Cheezum, OD, CPC, COPC

Thank you very much!!