Cataract Removal Surgery Targeted Probe and Educate Review Results - JF Part A

The Jurisdiction F, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for Current Procedural Terminology (CPT®) code 66984 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation. The findings of the claims reviewed from July 1, 2024 through September 30, 2024 are as follows:

Review Results

• 107 claims were reviewed with 13.20% error rate

Top Trending Errors

• Documentation Requirements for Cataract Surgery
• Medical Necessity for Cataract Surgery

Educational Resources

• LCD: Cataract Surgery in Adults (L37027)
• LCA: Billing and Coding: Cataract Surgery in Adults (A57196)
• Documentation Requirements
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 120
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 120

Education

Medical Necessity for Cataract Surgery

Per LCD L37027 cataract surgery is not considered medically necessary based on lens opacity only when there are no associated symptoms. Cataract surgery would be considered medically necessary if:

• There is symptomatic visual function impairment that cannot be corrected with glasses or contact lenses and is prohibiting the patient from performing activities of daily living.
• The cataract is inhibiting monitoring or treatment of related intraocular disease such as diabetic retinopathy.
• There is disease of the lens that threatens the patient’s vision or visual health.
• The cataract development has a high potential of accelerating due to a related or subsequent procedure and external beam radiation.
• Vitreoretinal surgery is planned, and the cataract is interfering with proceeding with the planned surgery.
• The patient developed anisometropia or aniseikonia after lens extraction in the first eye that is not tolerable and uncorrectable with glassed or contact lenses.

For additional information, reference Cataract Surgery in Adults LCD L37027.

Documentation Requirements for Cataract Surgery

Per LCA A57196 required documentation to support medical necessity includes:

• Patient symptoms that indicate visual functional impairment resulting in inability to perform activates of daily living satisfactorily. Activities of daily living include but are not limited to, reading, watching television, and driving.
• Best corrected visual acuity test under standard testing conditions supporting inability to correct the patient’s visual function with changes to glasses or contact lenses.
• Degree of lens opacity correlating impairment of best corrected visual acuity with cataract as primary cause of visual compromise.
• Documentation of patient’s desire to have surgical correction and that risks, benefits, and alternatives were explained.
• Appropriate preoperative ophthalmologic evaluation, which includes a comprehensive ophthalmologic examination.
• Any specialized ophthalmologic studies are completed for medically necessary reasons unique to that patient and study results
• When other ocular diseases are present, documentation that cataract is believed to be significantly contributing to impairment and/or interfering with treatment and specifically why surgery is being performed.

For additional information, reference Cataract Surgery in Adults LCD L37027 and LCA A57196.