0002 - Cataract Removal: Medical Necessity and Documentation Requirements

Dynamic List Information
Dynamic List Data
Issue Name
0002 - Cataract Removal: Medical Necessity and Documentation Requirements
Review Type
Complex
Provider Type
Ambulatory Surgical Center (ASC); Outpatient Hospital
MAC Jurisdiction
J6, J15, JE, JF, JH, JJ, JK, JL, JM, JN
Date
2017-02-01
RAC Type
Approved

Description

Documentation will be reviewed to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.

Affected Code(s)

66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, 66987, 66988,

Palmetto only- 66989, 66991

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.929- Post-Payment Review
4.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
5.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6.    42 CFR §405.986- Good Cause for Reopening  
7.    Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10- Anesthesia and Pain Management, §10.1- Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery; Effective 10/03/2003; Revised 02/15/2019
8.    Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §80- Eye, §80.10- Phaco-Emulsification Procedure - Cataract Extraction; §80.12- Intraocular Lenses (IOLs) Effective 10/03/03; Revised 02/15/2019
9.     Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 
10.    CGS LCD L33954- Cataract Extraction; Effective 10/01/2015; Revised 01/04/2024
11.    CGS LCA A56453- Billing and Coding: Cataract Extraction; Effective 10/01/2016; Revised 01/04/2024
12.    NGS LCD L33558- Cataract Extraction; Effective 10/1/2015; Revised 09/19/2019
13.    NGS LCA A56544- Cataract Extraction; Effective 08/01/2019; Revised  01/01/2024
14.    Noridian LCD L34203- Cataract Surgery in Adults; Effective 10/01/2015; Revised 07/30/2023
15.    Noridian LCD L37027- Cataract Surgery in Adults; Effective 10/10/2017; Revised 07/30/2023
16.    Noridian LCA A57195- Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised  01/01/2024
17.    Noridian LCA A57196- Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised  01/01/2024
18.    Palmetto LCD L34413- Cataract Surgery; Effective 10/01/2015; Revised 05/26/2022
19.    Palmetto LCA A56613- Billing and Coding: Cataract Surgery; Effective 06/13/2019; Revised  04/30/2023
20.    Palmetto LCA A53047- Complex Cataract Surgery: Appropriate Use and Documentation; Effective 10/01/2015; Revised 01/01/2022
21.    Novitas LCD L35091- Cataract Extraction (including Complex Cataract Surgery); Effective 10/01/2015; Revised 07/11/21
22.    Novitas LCA A56615- Billing and Coding: Cataract Extraction (including Complex Cataract Surgery); Effective 06/13/2019; Revised 07/11/2021
23.    First Coast LCD L33808- Cataract Extraction; Effective 10/01/2015; Retired 10/29/2019
24.    First Coast LCD L38926- Extraction (including Complex Cataract surgery); Effective 07/11/2021
25.    First Coast LCA A58592- Cataract Extraction (including Complex Cataract Surgery); Effective 07/11/2021
26.    AMA CPT Codebook