Medical Review

Cataract Removal - AK, ID, OR, WA Service Specific Post-Payment Final Findings

CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian's priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis.

This is to update providers of the claim review findings and closure of the file of Current Procedural Terminology (CPT®) code 66984 for AK, ID, OR, and WA.

Summary of Findings

Since the initiation of the review, 199 claims were reviewed from May 3, 2021 through November 16, 2021 with an overall claim error rate of 71.3% and payment error rate of 70.5%. The breakdown of those findings are as follows:

  • 57 claims were accepted.
  • 142 claims were denied in full for the following reasons:
    • Documentation was not received timely in response to the additional documentation request (ADR).
    • Documentation did not support medical necessity per LCD requirements.

If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.

Education

Paragraph Name Paragraph Details
Documentation Requirements for Cataract Surgery Per Local Coverage Determination (LCD) L37027 (JF) required documentation to support medical necessity must include:
  • Statement indicating specific symptomatic 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 at distance showing 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.
  • Attestation indicating patient's visual function impairment is believed not to be correctable by any other means.
  • Attestation indicating cataract is believed to be significantly contributing to impairment when other ocular diseases are present.
  • Statement that the patient wishes 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.
For additional information, reference Cataract Surgery in Adults LCD L37027 (JF).
Medical Necessity for Cataract Surgery Per Local Coverage Determination (LCD) L37027 (JF) 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 (JF).

Timely Submission of Documentation and 569PPs

It is the responsibility of Medicare providers to submit all documentation requested on the additional documentation requests (ADR) within the allotted time frame. Noridian allows 45 calendar days for the medical records to be received per the ADR request for post-payment reviews. On day 46, if the medical records have not been received, the claim will be denied provider liable with reason code 569PP. If there is no documentation to complete the medical review (MR), services billed on the claim cannot be supported.

A redetermination request should be submitted to Noridian within 120 days from the date of the 569PP denial. Contractors shall reopen the claim for review as long as all conditions are met. The determination made on the reopening claim has the potential to reverse non-covered dollars.

For additional information, refer to Internet-only Manual Pub 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6), and Social Security Act sections 1815(a), 1833(e) and 1862(a)(1)(A).

 

View references used in review. Further educational opportunities may be found under. Education and Outreach. If you are in need of an individualized education training event, contact the POE Department at mac@noridian.com. If you need coding assistance, please check your CPT®, HCPCS, ICD-10 books and your specific association.

Provider Action Required

File results and trending errors are being shared with all providers to assess compliance and billing practices if the service is provided within your facility. If your facility had claim documentation requested for this review, please refer to the individual result letter you received. You can also access individual determinations for claims that were requested from your facility by reviewing comments in either DDE or on the Noridian Medicare Portal (NMP).

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports medical necessity of Current Procedural Terminology (CPT®) code 66984.

Summary

This service specific post-payment file is now closed for JF and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices.

If you have any other questions, contact the JF Provider Contact Center at 1-877-908-8431.

 

Last Updated Fri, 03 Dec 2021 18:01:23 +0000