Billing and Coding: Cataract Surgery in Adults

**Documentation Requirements:**  
  
The following documentation must be present in the medical chart:  
  
 **For Cataract Surgery Patients:**

  1. The patient's chief complaint which conveys the symptoms, such as blurred vision, reduced contrast sensitivity or complaints of glare which are associated with impaired functionality.
  2. A unique statement indicating the specific symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function resulting in the patient's inability to function satisfactorily while performing Activities of Daily Life. Such activities typically include, but are not limited to, reading, viewing television, driving, or meeting vocational or recreational expectations. The patient's own words should be included in the statement where possible. If desired, completion of a VF-14 or VF-8R visual activities questionnaire (one for each eye) may be used.
  3. A best-corrected Snellen visual acuity at distance (and near if the primary visual impairment is at near) as determined by a careful refraction performed under standard testing conditions as appropriate must be recorded to establish the inability to correct the patient's visual impairment with a tolerable change to glasses or contact lenses. Neither uncorrected visual acuity nor corrected acuity with the patient's current prescription will satisfy this requirement. The refraction may be performed by the surgeon or by suitably trained staff in the surgeon's practice as permitted by law.
  4. A degree of lens opacity that correlates with the impairment of best-corrected visual acuity when cataract is determined to be the most likely primary cause of visual compromise after a full ophthalmic evaluation. This statement shall be supported by documented symptoms and physical findings in the medical record indicating that the patient's impairment of visual function is not believed to be correctable with a tolerable change in glasses or contact lenses.
  5. When concomitant ocular disease(s) is/are present that potentially affect visual function (e.g., macular degeneration or diabetic retinopathy), the statement should indicate that cataract is believed to be significantly contributing to the patient's visual impairment or a statement indicating the medical condition or circumstance and the specific reason for surgical intervention (e.g., "Cataract surgery is being performed to establish clear media for the treatment [or monitoring] of diabetic retinopathy).
  6. A statement that the patient desires surgical correction, and that the risks, benefits, and alternatives have been explained. When the surgery is not being performed to improve vision, there should be a statement that the patient understands that the surgery is being performed to address the specified medical condition or circumstance. For example, "cataract is impairing treatment and monitoring of diabetic retinopathy due to poor visualization of the retina" (or similar explanatory language). If vision is not expected to improve, the statement should include the patient's understanding of that fact.
  7. An appropriate preoperative ophthalmologic evaluation, which includes a comprehensive ophthalmologic exam (or its equivalent components occurring over a series of visits). Certain examination components may be appropriately excluded based on the specific condition and/or urgency of surgical intervention.
  8. Results and interpretation of specialized ophthalmic studies done for medically necessary reasons unique to the patient's situation.
  9. Results and interpretation of specialized ophthalmic studies that are **_not_** routinely expected to be routinely performed for routine cataract surgery with clear statements/explanation of the reasons they are needed to establish or exclude medical necessity.

**For Complex Cataract Surgery (CPT code 66982):**

The billing of CPT code 66982 is **not** related to the surgeon's perception
of the surgical difficulty. The use of this code is governed by the need to
employ devices or techniques not generally required/utilized in routine
cataract surgery. Every complex cataract surgery must have clear justification
to meet the requirements of its CPT descriptor. Therefore, it is strongly
recommended to include an initial supporting statement in the operative note.
For example:

  1. Indication for Complex Cataract Surgery: The patient required suturing a posterior chamber intraocular lens because of insufficient capsular support.
  2. Indication for Complex Cataract Surgery: Iris hooks were required to address a severely miotic pupil.
  3. Indication for Complex Cataract Surgery: Trypan blue dye was needed to adequately visualize the lens capsule in the presence of a mature cataract.

In general, all documentation supporting medical necessity must be legible,
maintained in the patient's medical record, meet all Medicare signature
requirements, and must be made available to the A/B MAC or other CMS review
entity upon request.

**Utilization Requirements**

Medicare benefits include a conventional intraocular lens (IOL) following
cataract surgery, facility supplies and physician services to implant the
conventional IOL and one pair of glasses or contact lenses as a prosthetic
device post-operative.

Ancillary tests that are **_not_** routinely indicated in the preoperative
workup for cataract surgery (see "Specialized Ophthalmic testing") will not be
considered a covered benefit(s) unless medical necessity is clearly documented
in the patient's record.

If an optometrist or an ophthalmologist who is not the surgeon performs
biometry for intraocular lens power calculation, he/she should do so in
coordination with the operating surgeon so that only one procedure is
necessary. If the operating surgeon repeats biometry due to inadequacy of the
first study, the original eye care physician/provider should anticipate not
being reimbursed for the study.

When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222,
H26.223, H26.211, H26.212, H26.213, E08.36, E09.36, E10.36, E11.36, E13.36,
H28 note that coding guidelines require that the ICD-10 code for the
underlying condition must appear and be coded first on the claim. For ICD-10
codes H26.31, H26.32, H26.33, H26.8, coding guidelines require that the
causative agent be identified on the claim.