Article - Billing and Coding: Cataract Extraction (A56453)

CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33954Cataract Extraction.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)For CPT code 66982, complex cataract extraction, to be reasonable and necessary, the procedure should require devices or techniques not generally used in routine cataract surgery.ICD-10-CMDOCUMENTATION REQUIREMENTS for COMPLEX CATARACT SURGERY (CPT Code 66982)H20.21-H20.23, H21.261-H21.263, H21.29, H21.561-H21.563Report if the operative note indicates the use of an endocapsular ring to partially occlude the pupil.H21.271-H21.273, H26.211-H26.213, H26.221-H26.223,Report if the operative note indicates micro iris hooks were inserted through four (4) separate corneal incisions, Beechler or similar expansion device, synechialysis utilizing papillary stretch maneuvers or, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of the iris sphincter.H21.221-H21.223Report if the operative note indicates that a permanent intraocular suture or a capsular support ring was employed to place the intraocular lens in a stable position.H21.531-H21.533Report if the operative note indicates a capsular support ring was employed or an endocapsular support ring was used for partial occlusion of the pupil.H21.81, H21.89, H21.9,H22, H25.011-H25.013, H25.11-H25.13, H25.031-H25.033, H25.041-H25.043, H25.811-H25.813, H25.89, H25.9, H26.001-H26.003, H26.011-H26.013,H26.031-H26.033, H26.041-H26.043 H26.051-H26.053, H26.061-H26.063, H26.09, H26.121-H26.123, H26.31-H26.33, H26.8, H28, E08.36, E09.36, E10.36, E11.36, E13.36, Q13.0, Q13.2Report if the operative note indicates the use of micro iris hooks inserted through four (4) separate cornea incisions, use of a Beechler or similar expansion device, synechialysis utiliziaing papillary stretch maneuvers creation of multiple sphincterotomies with scissors, a sector iridotomy with suture repair of iris sphincter was performed, or a permanent intraocular suture, capsular support ring, or endocapsular support ring was used for partial occlusion of the pupil.H25.89Report if the operative note indicates dye was used to stain the anterior capsule.H25.21-H25.23This code must be used with H40.89 Phacolytic glaucoma or dye staining of the anterior capsule.H26.101-H26.103, H26.111-H26.113, H26.131-H26.133, H26.20Report if the operative note indicates micro iris hooks were inserted through four (4) separate corneal incisions, Beechler or similar expansion device, synechialysis utilizing papillary stretch maneuvers, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, intraocular lens implant was supported by using a permanent intraocular sutures, a capsular support ring was employed or a primary posteriod capsulorhexis was performed.H28Report if the operative note or postoperative records indicate an extraordinary amount of work was involved in the preoperative or postoperative care.H27.10, H27.111-H27.113, H27.121-H27.123,H27.131-H27.133, Q12.1, Q12.2, Q12.4, Q12.8, Q12.9Report if the operative note indicates: the intraocular lens was supported by using permanent intraocular sutures or a capsular support ring.H57.00-H57.04, H57.051-H57.053, H57.09, H57.9Report if the operative note indicates the use of micro iris hooks inserted through four (4) separate incisions, Beechler or similar expansion device, synechialysis utilizing papillary stretch maneuvers, multiple sphincterotomies created with scissors, a sector iridotomy with suture repair of the iris sphincter, or an artificial prosthetic iris was placed in the eye.Q13.1Report if the operative note indicates the intraocular lens was supported in the eye by using permanent intraocular sutures, a capsular support ring was employed, or an endocapsular ring was used to for partial occlusion of the pupil.