Draft Article - Billing and Coding: Cataract Extraction (DA59556)

CMS National Coverage PolicyItalicizedfont represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Title XVIII of the Social Security Act 1862(a)(7) excludes routine physical examinations.Title XVIII of the Social Security Act, 1862 (a)(1)(A) allows coverage and payment for only those services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare Payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations 42 CFR CH.IV [411.15(b)(2)&(3)and(o)(1)&(2)] Services excluded from coverageCode of Federal Regulations 42 CFR CH. IV [416.65] Covered surgical proceduresCMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 80.10, Phaco-Emulsification Procedure-Cataract ExtractionCMS Manual System, Pub 100-04,Medicare Claims Processing ManualChapter 12, 40.6, 40.7, Claims for Multiple Surgeries, Claims for Bilateral SurgeriesArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy DL39716 Cataract 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 following documentation must be present in the medical chart:The 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 Cataract Surgery Patients: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.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 patients own words should be included in the statement where possible. If desired, completion of a VF-14 or VF-8R visual activities questionnaire (1 for each eye) may be used.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 patients current prescription will satisfy this requirement. The refraction may be performed by the surgeon or by suitably trained staff in the surgeons practice as permitted by law.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.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 patients 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).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.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.Results and interpretation of specialized ophthalmic studies that are not 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 Anticipated Placement of an Intraocular Lens (IOL):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.Since the patient and surgeon determine the medical necessity for cataract surgery, only the surgeon may order and receive reimbursement for the professional component of an A-scan or partial coherence interferometry service. For circumstances where an adequate view of the intraocular structures cannot be obtained because of dense cataract, B-scan ultrasound testing should be considered to assess such structures and determine the need for surgery. B-scans performed without documented evidence of a dense cataract or evidence that the cataract precluded visualization of the posterior segment of the eye including the vitreous and/or retina will be considered not medically necessary.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.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, such as:Insertion of iris retractors through additional incisionsMechanical expansion of the pupil using hooksCreation of a sector iridectomy with subsequent suture repair of iris sphincterUse of a Malyugin ring and multiple iris sphincterotomies created with scissors.The need to support the lens implant with permanent intraocular suturesPlacement of a capsular support ring necessary to allow secure placement of an intraocular lensPerformance of pediatric cataract surgery with intraocular lens insertionUse of intraocular dyes (e.g., trypan blue or indocyanine green) to stain the lens capsule in the setting of a mature cataractEvery complex cataract surgery must have clear justification to meet the requirements of its CPT descriptor and should be clearly stated in the operative report.For Second Eye Surgery:If a significant cataract is present in the second eye, surgery is generally not performed in both eyes at the same time because of the potential for bilateral visual loss. If bilateral cataract extraction is performed on both eyes, on the same date of service, known as Immediate Sequential Bilateral Cataract Surgery, the medical record must document the rationale, and that the patient has been apprised of the risks and benefits of the procedure and available alternatives.In the more common situation where surgery is performed sequentially in the other eye on separate days for bilateral visually symptomatic cataracts, the appropriate interval between the first-eye surgery and second-eye surgery is influenced by several factors:The patient's visual needs,The patient's preferences,Visual function in the second eye,The medical and refractive stability of the first eye,The need to restore binocular vision and resolve anisometropia,Allow an adequate interval of time to elapsed to evaluate and treat early postoperative complications in first eye, such as endophthalmitis; and/orLogistical and travel considerations of the patient.The patient and the ophthalmologist should discuss the benefits, risks, need, and timing of second-eye surgery when they have had the opportunity to evaluate the results of surgery on the first eye, considering the above factors.If the decision to perform cataract extraction in both eyes is made prior to the first (sequential) cataract extraction, the documentation must support the medical necessity for each procedure to be performed. If cataract extraction is performed due to anisometropia, the medical record must substantiate the presence of significant aniseikonia secondary to anisometropia arising from the first cataract extraction with IOL implant. The medical record must reflect that the aniseikonia is visually significant to the patient by documenting the patient's subjective complaints and must also document that anisometropia is present by determination of the refractive error in both eyes after the first cataract surgery.Utilization RequirementsSpecialized Ophthalmic Testing:For circumstances where the placement of an intraocular lens (IOL) is anticipated, A-scan ultrasound testing or partial coherence interferometry, keratometry (may be from corneal topography), and IOL calculations and selection would be anticipated to be performed. Additional ancillary testing as appropriate in the establishment or exclusion of medical necessity. This should be directed by specific patient complaint or symptom where possible.The following ancillary tests are not routinely indicated in the preoperative workup for cataract surgery, and if performed, will not be considered a covered benefit unless medical necessity is defended by a statement in the patient's record:Potential vision testing,Corneal Topography,Anterior or Posterior Segment Ocular Coherence Tomography,Formal visual fields,Fluorescein angiography,External photography,Corneal pachymetry/Specular microscopy,Specialized color vision testing,Electrophysiologic testing,Fundus photography,Extended ophthalmoscopy, andOphthalmic ultrasound B scanIn general, any performed ancillary testing must be conducted so as not to deliberately bias the decision toward the performance of surgery (e.g., glare testing done on abnormally high settings inconsistent with the instructions of the testing devices manufacturer, etc.).