The Centers for Medicare and Medicaid Services (CMS) have contracted with StrategicHealth Solutions (strategichs.com/smrc ), LLC, to perform auditing activities as a Supplemental Medical Review Contractor (SMRC). SMRCs review medical records and documentation to determine whether claims were billed according to Medicare coverage, coding, payment, and billing regulations. The review may include vulnerabilities identified by CMS data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations, and federal oversight agencies.

In addition to the above contingency fee-based contractor, CERT audits are also being conducted by other CMS contractors, such as AdvanceMed (www.nciinc.com/about-us/advancemed ), a CERT review contractor, as well as a Program Safeguard Contractor (PSC). As the CERT review contractor, AdvanceMed is responsible for:

• Selecting a random sample of claims that have been received by each Medicare contractor every month.
• Reviewing the selected claims and associated medical record documentation to determine whether the claim was appropriately adjudicated according to Medicare regulations/guidelines.

On its website, StrategicHealth Solutions lists the issues currently being audited wherein complex cataract surgery (CPT code 66982) is listed as one of the issues, and, indeed, the Midwest has been heavily audited not only for complex cataract surgery with insertion of an IOL but also for regular cataract extraction with insertion of an IOL (CPT code 66984).

I recently was made aware of a CERT audit wherein both the cataract surgery and MIGS surgery were found not medically necessary due to a lack of proper documentation in the physician and ASC chart.

Medical necessity is the foundation of the Medicare program. Coverage and subsequent payment of a Medicare service depends on that service being medically necessary and medically reasonable. This CERT audit demanded recoupment of the facility fee from the ASC. The medical necessity must be supported in the chart documentation by both the ASC and the physician.

CHART DOCUMENTATION FOR CATARACT SURGERY

The overriding mandate in ASC chart documentation is that an ASC must stand on its own and contain all of the clinical information and narrative rationale necessary to demonstrate medical necessity — the physician’s medical decision-making rationale and any other narrative or diagnostic information that supports the surgery.

Medicare’s Medical Necessity chart documentation is not incorporated into the Conditions for Coverage guidelines with which most ASC nurse managers are familiar and prepared to handle. Demand for monies already paid to the ASC can occur as a primary audit or secondary to a physician audit, if the physician’s chart documentation is found to be insufficient in providing enough written narrative material in response to request for information; subsequently, the surgeries are denied on the basis of their not being medically necessary. If the ASC doesn’t pre-check the physician’s chart before surgery, there is no way of knowing whether or not the required material is included.

I have designed several checklists to assist in ascertaining that the chart documentation is complete (see Tables 1 and 2). Most of this information will be gleaned from the physician’s records. Of course, it is extra paperwork for the ASC; however, it is probably easiest to make it a requirement for scheduling, having the practice use the checklist to amend its chart documentation for long-term purposes (it will also be of benefit for defending audits). In addition, the checklist should be used as a coversheet when the practice sends the information to the ASC.

Let’s take a look at what should be included in ASC documentation for regular cataract surgery with IOL insertion (CPT code 66984) and complex cataract surgery (CPT code 66982). See Table 1.

TIPS ON CHART DOCUMENTATION FOR COMPLEX CATARACT SURGERY

• Complications versus complex cataract surgery designation. Complications during cataract surgery, such as vitreous loss or dropping the crystalline or IOL into the posterior segment, do not qualify the case as complex. More often than not, cases can be determined as complex preoperatively.
• The use of dye. This in and of itself was never enough to qualify a case as complex. It is the presence of a dense cataract with little or no view of the posterior segment that is the qualifier. Usually, if the physician can see in and the patient can see out, then the case is not sufficient to qualify as complex unless there are other factors. Although the use of dye alone does remain in one medicare administrative contractor’s (MAC) local coverage determination (LCD), it should not be used as a qualifier. Other MACs state the use of dye in conjunction with the presence of a dense cataract qualifies the case to be considered complex; however, it is the presence of the dense cataract and not the use of the dye that is the qualifier.
• During residency training, dye and temporary pupillary expansion devices are used quite often. These cases should be coded as if performed by the attending physician. Their use for training residents does not qualify the case as complex. Furthermore, in the early stages of practice, many surgeons continue using dye and pupillary expansion devices. If the mandatory qualifiers are not in place, then the case should not be coded as complex.
• Use of intraoperative medications for dilating or maintaining dilation, such as Shugarcaine or phenylephrine and ketorolac injection 1% / 0.3% (Omidria, Omeros) is not a qualifier.
• EMR systems contribute to faulty chart documentation in many aspects, including cookie cutter and non-individualized chart documentation; lack of ability to provide customized rationales for surgery, thereby not supporting necessary medical necessity support; lack of proper templates to guide documenting such things as dilated and non-dilated pupillary sizes; and many others.

CHART DOCUMENTATION FOR MIGS DEVICES

The first LCD regarding MIGS coverage was issued by NGS Medicare with an effective date of Dec. 1, 2017. (Search the web for “NGS Medicare LCD L37244” for easiest access.) Although this applies to physician coding, it applies to ASCs as well; hopefully, this will engender a paradigm shift in the way ASCs set up their protocols for chart documentation. Most likely, other MACs will follow suit.

Here are some highlights from that policy:

• “NGS considers one iStent [Glaukos] or CyPass [Alcon] device per eye medically reasonable and necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently being treated with an ocular hypertensive medication and the procedure is being performed in conjunction with cataract surgery. The Xen [Allergan] device is not considered medically reasonable and necessary.” (Note: All three devices are FDA approved.)
• “Rationale for Determination … the possibility of achieving long-term glaucoma control with a single operation, and elimination of risk of bleb failure with subsequent cataract surgery when glaucoma surgery is performed first. Therefore, an ophthalmologist may reasonably choose to perform a combined surgery because of these perceived advantages to an individual patient … these procedures offer a reduction in IOP, decreased dependence on glaucoma medications, and an excellent safety profile.” (Note: This rationale should be added to the physician’s narrative statement in the chart).
• “CPT/HCPCS CODES. The CPT codes in Group 1 are considered medically necessary when the indications of Coverage are met. The CPT codes in Group 2 are considered not medically necessary.” (Note: Group 1 codes — 0191T and 0474T, iStent and CyPass respectively — are for a single initial insertion, whereas the Group 2 codes — 0376T, 0449T and 0450T, iStent, CyPass and XEN, respectively — are CPT codes used for additional device insertion at the same session and are considered an off label use.)

Further associated information states, “The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The medical record and/or test results documenting medical necessity should be maintained and made available on request.”

CASE STUDY: ASC AUDIT TRIGGERED BY LACK OF MEDICAL NECESSITY DOCUMENTATION FOR THE CATARACT & MIGS PROCEDURE

Recently, an ASC CERT audit on documentation of medical reasonableness and necessity of cataract and MIGS surgery was received with funds potentially being taken back from the ASC based on the lack of medical necessity for the procedures based on the chart documentation provided to the CERT auditor. If the case is not won on appeal, the monies will be offset from future Medicare reimbursements.

The error code assigned to the claim was for insufficient documentation that cited the following missing information:

• Clinical documentation prior to a surgical intervention date supporting the medical necessity for the cataract surgery with IOL plus insertion of a MIGS device, including results of diagnostic testing to determine appropriateness of the procedure
• Clinical documentation dated prior to the surgical date that supports a plan for cataract surgery with IOL with insertion of a MIGS device.

The request then proceeds to list the documentation that was received:

• Operative notes of surgery documenting date of surgery
• H&P appropriately dated prior to surgery
• Preoperative data sheet documenting cataract and open-angle glaucoma
• OR record for date of surgery
• KPE IOL OS and MIGS device
• Anesthesia record
• Consents for surgery and anesthesia
• Discharge instructions

It is apparent to anyone experienced in handling audit requests that the ASC response contained all of the typical medical data-driven information, but none of the chart documentation to support that the services were medically reasonable and medically necessary per descriptions throughout this review. This is a heavy blow to the ASC if they lose this type of audit, because the ASC will have to pay back the cost of the device as well as the rest of the facility payment that will be recouped.

PROCEED WITH CAUTION

If successful, these types of audits can be expected to increase in frequency, causing a huge potential financial problem for ASCs. It is imperative that the ASC revise the parameters regarding what is considered mandatory chart documentation for cataract and MIGS surgery, and, perhaps, not schedule these cases until after the pertinent chart documentation is obtained and reviewed (Table 2). ■

CPT codes copyrighted 2018 American Medical Association

Resources

1. NGS Medicare. Local Coverage Determination (LCD): Micro-Invasive Glaucoma Surgery (MIGS) (L37244).
2. Asbell RL. Complex Cataract Surgery: Audit Considerations, Coding & Compliance. Ocular Surgery News. Ahead of press.