NOTE: All in-article links open in a new tab.

Cataract Awareness Month June 2023

Published on 

Wednesday, June 14, 2023

 | Coding 
 | Documentation 
 | Medicare Coverage 

Did You Know?

June is cataract awareness month and according to the National Eye Institute (https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts), most cataracts are age-related, there are no early symptoms of cataracts and later symptoms includes blurry vision, colors that seem faded, sensitivity to light, trouble seeing at night and double vision.

 

A cataract is diagnosed by a dilated eye exam and the treatment is surgery. Cataract surgery is one of the most common operations in the United States. In fact, more than half of all Americans aged eighty or older either have cataracts or have had surgery to get rid of cataracts.

 

Why it Matters?

Being a high-volume surgery, means scrutiny by CMS and Medicare Contractors to assure documentation in the medical record supports medical necessity of the procedure.

 

Recovery Audit Contractors

RAC Issue 0002 cataract removal (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics-Items/0002-Cataract-Removal-Medical-Necessity-and-Documentation-Requirements) has been an approved complex review for procedures performed in the outpatient hospital setting and ambulatory surgery centers (ASCs) since February 1, 2017. RACs will review documentation to determine if cataract surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) are included on this RAC issue webpage.

 

Comprehensive Error Rate Testing (CERT)

In the 2021 and 2022 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table D1: Top 20 Service Types with Highest Improper Payments: Part B (https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0).

 

2021 CERT Report

The improper payment rate for this surgery was 12.7%. The CERT cited two types of errors, insufficient documentation, and incorrect coding, as being the cause of improper payments. Specifically,

the insufficient documentation project improper payment was $190,495,888 and the incorrect coding improper payment was $27,844,602.

 

2022 CERT Report

The improper payment rate for this surgery was 8.3%. Unlike 2021, 100% of the errors were due to insufficient documentation. The project improper payment rate was $146,067,233.

 

Medicare Administrative Contractors (MACs)

 

JE and JF MAC: Noridian

Cataract surgery has been a review target for Noridian MAC jurisdictions for a few years. Their most recent review findings were for claims with dates of service from January 1, 2023 through March 31, 2023.

 

Review results for jurisdictions were published April 12, 2023:

 

Noridian’s review results articles include top denial reasons, educational resources, and education regarding the medical necessity for cataract surgery.

 

Supplemental Medical Review Contractor (SMRC)

On February 16, 2022, the SMRC published a notification of their intent to review cataract surgeries performed in the physician office, outpatient hospital and specialty facility clinical access hospitals. In the background section of the notification, they note that “this type of surgery has been a topic of interest for the Office of 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.”

 

The SMRC published review results on September 27, 2022 (https://noridiansmrc.com/completed-projects/01-302/). The error rate was 51%.

 

What Can You Do?

With so many entities focused on reviewing cataract surgery claims, moving forward providers should:

  • Respond to ADRs in a timely manner,
  • Become familiar with medical necessity indications and documentation requirements detailed in Medicare coverage documents (NCDs, LCDs, LCAs),
  • Be aware of who is performing cataract surgery reviews,
  • Read published review results to understand reasons for denials and ways to prevent future denials, and
  • Ensure physicians performing these procedures are also aware of Medicare coverage requirements.
Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.