coding & reimbursement
Visits Prior to Second Eye Cataract Surgery
How to Decide Who Should See the Patient and When Such Visits Should Be Reimbursed

By Suzanne L. Corcoran, COE

Practices grapple with whether to charge Medicare for the visit prior to cataract surgery on the second eye, and who should be examining the patient. The question of who should see the patient is especially confusing in mixed ophthalmology/optometry practices. Here are some reasons for ophthalmologists to do the interim visit and how to bill carriers.

Q: Who needs to see the patient prior to cataract surgery for the second eye? Although the patient is diagnosed with cataracts in both eyes and will likely desire both procedures, the need for the surgeon to see the patient before the second surgery is supported in several ways.

First off, the ophthalmologist provides informed consent prior to each surgery. In the American Academy of Ophthalmology's (AAO) Cataract in the Adult Eye, it states: "Consideration of the appropriate interval between the first-eye surgery and second-eye surgery is influenced by several factors: the patient's visual needs, the patient's preferences, visual acuity or function in the second eye, the medical and refractive stability of the first eye, the need to develop binocular vision and symptomatic anisometropia as well as logistical concerns of the patient in traveling back and forth to the physician's office.

The ophthalmologist and patient and should discuss the benefits and risks of second-eye surgery when they have had the opportunity to evaluate the results of surgery on the first eye.

 Prior to performing surgery on the second eye, the patient's first eye should have a stable postoperative refraction and the patient should perceive improved function, and sufficient time should have elapsed to evaluate and treat early postoperative complications, such as endophthalmitis.

Additionally, the malpractice carrier, OMIC, publishes information that states it is the surgeon's responsibility to secure informed consent in their risk management document and discusses the interval between cataract surgeries. The company writes:

"INFORMED CONSENT"

"Personally obtain the patient's informed consent: this legal duty cannot be delegated."

Later in the document it says:

"Prior to proceeding with the second surgery, ensure that the criteria noted above have been met, and document this carefully in the record. Once you are satisfied that it is safe to proceed, again obtain and document informed consent for the second-eye surgery."

So, the surgeon conducts the second exam to determine with the patient the medical necessity of a second procedure. Medicare carriers clearly indicate that the medical necessity for the second-eye surgery is determined after the first surgery, justifying a second exam.

AAO and third-party insurers both stress the importance of an interim period between surgeries, and most carriers have published the following type of statement regarding the indications and limitations of coverage and/or medical necessity:

"Surgery should not be performed on both eyes on the same day because of the potential for bilateral vision loss.

The patient needs sufficient time to assess results of his or her first eye surgery to determine the need and appropriate timing for surgery in the second eye."

Q: What about billing Medicare? Some Medicare carriers have published instructions or policies that prohibit payment for the exam prior to second-eye surgery. However, a reading of the above discussions, including the quote from Medicare carrier policies, supports a claim for this visit. Documentation is critical. If the visit prior to the first eye surgery says something like, "3+ NSC OD>OS" and the plan is to schedule both procedures, the carrier will believe that the second exam is not necessary.

The medical record should reflect the surgeon's actual thought processes, where the real plan is to perform the first eye surgery and, if everything goes well and the patient wants to proceed, then perform the second procedure. In addition, the visit at which the decision to proceed with the second eye surgery must be carefully documented. If the only documentation is a postop exam on the first eye, there is no support for an exam charge.

Q: What level of service is appropriate for this second exam? Choosing a level of service is based on the documentation and medical necessity, and a full discussion is beyond the scope of this article. However, one would not expect to require a comprehensive eye exam if one was conducted recently. When the two surgical procedures are close together in time, many elements of the exam will not need to be repeated.

On the other hand, the patient now presents with a completely different set of complaints than were expressed prior to the first surgery — tailor the exam to the patient's need.

Liability Issues

There is considerable liability to the practice when the surgeon does not examine the patient prior to second-eye surgery. This extends to third-party payer scrutiny as well as malpractice concerns. We strongly advise that a policy be implemented to ensure that patients see the surgeon prior to the second cataract surgery. Whether to charge for this exam is up to the individual practice, although we believe a visit is warranted when appropriately documented.

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.