Knowledge Base Article

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.

In addition to age, you may be at a higher risk of developing cataracts if you:

• Have certain health problems like diabetes
• Smoke
• Drink too much alcohol
• Have a family history of cataracts
• Have had an eye injury, eye surgery, or radiation treatment on your upper body
• Have spent a lot of time in the sun
• Take steroids

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 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 2023 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table G1: Improper Payment Rates by Service Type: Part B. The improper payment rate was 8.2% with the projected improper payment of $149,241,566.

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 published on April 15, 2024 for claims with dates of service from January 1, 2024 through March 31, 2024:  

• Noridian JE error rate was 22% down from 48.67% in April 2023.
• Noridian JF was 43.6% down from error rate 45.88% in April 2023.

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

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.