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

The Jurisdiction E, 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 quarterly edit effectiveness results from January 1, 2024 through March 31, 2024 are as follows:

Top Denial Reasons

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

Educational Resources

• Local Coverage Determination (LCD): Cataract Surgery in Adults (L34203)
• Local Coverage Article (LCA): Billing and Coding: Cataract Surgery in Adults (A57195)
• Documentation Requirements
• National Coverage Determination (NCD): Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (10.1)
• LCA: Dropless Cataract Surgery (A53916)
• Internet-Only Manuals (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 120
• IOM, Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 32, Section 120

Education

Documentation Requirements for Cataract Surgery

Per LCA A57195 required documentation to support medical necessity must include:

• 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 L34203 and LCA A57195.

Medical Necessity for Cataract Surgery

Per LCD L34203 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 L34203.