01-302 Cataract Surgery Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Cataract Surgery billed on dates of service from January 1, 2019 through December 31, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Medicare Part B program provides coverage for treatment by an ophthalmologist for certain medical conditions, including wet age-related macular degeneration (wet AMD), cataracts, and glaucoma. For these services to be covered, the service must fall within a statutorily defined benefit category, be reasonable and necessary for the diagnosis or treatment of illness, and not be excluded from coverage.

This type of surgery has been a topic of interest for the Office of the Inspector General (OIG) for a number of years. The OIG looked into surgery in both the outpatient facility and ambulatory service center settings. CMS data reflects a potential vulnerability.

Reason for Review

The SMRC is tasked with performing claim review on a sample of Home Health claims from January 1, 2020 through December 31, 2020. The SMRC will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance. The SMRC will focus on CY 2019.

Claim Sample Detail

POS / TOB CPT
  • POS 11: Office
  • TOB 13X: Hospital Outpatient
  • TOB 85X: Special Facility Clinical Access Hospital
  • 66982: Removal of cataract with insertion of lens, complex
  • 66984: Removal of cataract with insertion of lens, simple

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Physician/Non Physician (NPP) order or evidence of intent to order
  2. Operative / procedure report
  3. History and Physical reports (include medical history and current list of medications)
  4. Comprehensive preoperative ophthalmologic evaluation including but not limited to: examination/testing, best corrected Snellen visual acuity and corrected vision with glasses or contacts
  5. Visual field measurement/documentation
  6. Visual Fields Studies
  7. All Visual Field Testing
  8. Photographs showing visual impairment
  9. Documentation to support cataract removal
  10. Medical record documentation to support the dates of service billed on the claim
  11. Diagnostic Studies, including visual acuity and glare tests
  12. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  13. Signed Consent Form
  14. Documentation supporting the diagnosis code(s) required for the item(s) billed
  15. Practitioner, nurse, and ancillary progress notes
  16. Beneficiary’s medical records (which may include; practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary
  17. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  18. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  19. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  20. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  21. Signature attestation and credentials of all personnel providing services
  22. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician

References/Resources

  • Social Security Act (SSA) Title XVIII, §1815(a). Payment to Providers of Services.
  • SSA, Title XVIII, §1833(e). Payment of Benefits.
  • SSA, Title XVIII, §1833(e). Payment of Benefits.
  • SSA, Title XVIII, §1862(a)(7). Excludes Routine Physicals.
  • SSA, Title XVIII, §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
  • SSA, Title XVIII, §1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
  • SSA, Title XVIII, §1893(b). Medicare Integrity Program.
  • Code of Federal Regulations (CFR) Title 42, §405.904. Determinations, Redeterminations, Reconsiderations, and Appeals under Original Medicare (Part A and Part B).
  • CFR. Title 42, §410.28. Hospital or CAH diagnostic services furnished to outpatients: Conditions.
  • CFR, Title 42, §410.32. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and other Diagnostic Tests: Conditions.
  • CFR, Title 42, §411.15(k)(l). Particular Services Excluded from Coverage.
  • CFR, Title 42, §424.5 (a)(6). Basic Conditions.
  • CFR, Title 42, §424.535. Revocation of enrollment in the Medicare Program.
  • CFR, Title 42, §416.65. Covered surgical procedures.
  • CFR, Title 42, §416.930(c)(2). Need to follow prescribed treatment.
  • CFR, Title 42, §482.24(c)(1). Condition of Participation: Medical Record Services.
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 10. Hospital Services Covered Under Part B.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.4. Outpatient Diagnostic Services.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30.1. Provider-Based Physician Services.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30.4. Optometrist’s Services.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.3 Examples of Not Reasonable and Necessary.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80. Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6. Requirements for Ordering and Following Orders for Diagnostic Tests.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 120. Prosthetic Devices.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Sections 10, 20, and 90. General Exclusions from Coverage.
  • Medicare National Coverage Determinations (NCD) Manual, (MNCDM), Publication 100-03, Chapter 1, Section 10.1. Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery.
  • MNCDM, Publication 100-03, Chapter 1, Sections 80.10-80.12 Phaco-Emulsification Procedure-Cataract Extraction and Interocular Lenses (IOLs).
  • MNCDM, Publication 100-03, Chapter 1, Part 2, Section 140.5 Laser Procedures.
  • MNCDM, Publication 100-03, Chapter 1, Part 4, Section 220.5. Ultrasound Diagnostic Procedures.
  • CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Sections 50 and 110.5.2. Financial Liability Protections.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 23. Fee Schedule Administration and Coding Requirements.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2. Billing Requirements for Global Surgeries.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.4. Payment for Terminated Procedures.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.6. Claims for Multiple Surgeries.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.7. Claims for Bilateral Surgeries.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 14, Section 40.3. Payment for Intraocular Lens (IOL).
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 10. Hospital Outpatient Prospective Payment System (OPPS).
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1. General Billing Guidelines.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4. Reasonable and Necessary Provisions in LCDs.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.3. DRG validation.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.2. Time Frames for Submission.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(A). Additional Documentation Requests.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. Documents on which to Base a Determination.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3. Diagnosis Code Requirements.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5. Denial Types.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.1. Coverage Determinations.
  • Local Coverage Determination L33558. Cataract Extraction. Effective October 1, 2015.
  • LCD L33808. Cataract Extraction. Effective October 1, 2015.
  • LCD L33954. Cataract Extraction. Effective October 1, 2015.
  • LCD L34615. Visual Fields. Effective October 1, 2015.
  • LCD L34394. Visual Field Testing. Effective October 1, 2015.
  • LCD L34394. Visual Field Testing. Effective October 1, 2015.
  • LCD L33574. Visual Field Testing. Effective October 1, 2015.
  • LCD L33766. Visual Field Examination. Effective October 1, 2015.
  • LCD L34203. Cataract Surgery in Adults. Effective October 1, 2015.
  • LCD L34413. Cataract Surgery. Effective October 1, 2015.
  • LCD L35091. Cataract Extraction. Effective October 1, 2015.
  • LCD L37027. Cataract Surgery in Adults. Effective October 1, 2015.
  • Local Coverage Article A53047. Billing and Coding; Complex Cataract Surgery. Effective October 1, 2015.
  • LCA A57483. Billing and Coding: Visual Fields. Effective October 31, 2019.
  • LCA A52417. Visual Fields Testing – Supplemental Instructions Article. Effective October 1, 2015.
  • LCA A56799. Billing and Coding: Billing and Coding for Visual Fields Testing. Effective October 1, 2018.
  • LCA A56551. Billing and Coding: Billing and Coding for Visual Fields Testing. Effective August 1, 2019.
  • LCA A57637. Billing and Coding: Visual Field Examination. Effective October 3,2018.
  • LCA A53916. Dropless Cataract Surgery. Effective October 1, 2015.
  • LCA A53918. Dropless Cataract Surgery. Effective October 1, 2015.
  • LCA A53472. Billing and Coding: Pre/Postoperative Care: Date of Service. Effective date October 1, 2015.
  • LCA A56453. Billing and Coding; Cataract Extraction. Effective October 1, 2016.
  • LCA A56544. Billing and Coding; Cataract Extraction. Effective August 1, 2019.
  • LCA A56613. Billing and Coding; Cataract Surgery. Effective June 13, 2019.
  • LCA A56615. Billing and Coding; Cataract Extraction. Effective June 13, 2019.
  • LCA A56869. Billing and Coding: Use of Laterality Modifiers. Effective date September 9, 2019.
  • Local Coverage Article A57195. Billing and Coding; Cataract Surgery in Adults. Effective October 1, 2019.
  • LCA A57196. Billing and Coding; Cataract Surgery in Adults. Effective October 1, 2019.

Last Updated Nov 9, 2021