The question keeps coming up: May we bill Medicare and other payers for an exam following first-eye cataract surgery? There is a lot of disagreement on the answer.

Q. Can a surgeon determine the need for second-eye cataract surgery prior to the first procedure?

A. Although cataracts in both eyes may be diagnosed initially, the evaluation before the first cataract operation does not establish the need for the second operation; the decision for surgery must be made prior to each procedure. The patient and the surgeon hope for a good outcome, but it cannot be guaranteed in advance, so the surgeon needs to evaluate the patient and obtain informed consent again.

This is supported by several sources. One Medicare contractor says, “The patient and ophthalmologist should discuss the benefit, risk and timing of second eye surgery when they have had the opportunity to evaluate the results ... on the first eye.”¹

The AAO agrees: “The indications for the second-eye surgery are the same as for the first eye. The outcome of surgery on the first eye may affect the timing of the second eye surgery.”²

The exam generally cannot be delegated. A malpractice carrier states: “Personally obtain the patient’s informed consent: this legal duty cannot be delegated” and, “Once you are satisfied that it is safe to proceed, again obtain and document informed consent for the second eye surgery.” It also notes, “Obtain consent for each cataract procedure.”³

Q. But is this visit billable?

A. Maybe, depending on the chart notes. Notations in the chart may nullify reimbursement for the exam prior to the second cataract operation. If the surgeon writes, “cataract surgery OU”, or “cataract surgery OD then OS” in the plan prior to the initial operation, the implication is that the decision for both procedures has already been made and a subsequent exam is redundant. Likewise if there is only a postoperative exam of the operated eye, with a notation to proceed in the fellow eye.

Q. What documentation is required?

A. Generally, documentation requirements for second-eye surgery are the same as for the first eye, especially impairment of activities of daily living (ADL). A repeat comprehensive exam may not be required by the patient’s condition, but the exam must include the pertinent elements.

The AAO Preferred Practice Pattern states that no single criteria, by itself, is sufficient to determine the need for cataract surgery. The following points, taken together, may support a decision to proceed:

• Objective evidence that a cataract is present
• Visual function that does not meet the patient’s needs, such as lifestyle complaints
• Reduced visual acuity
• Good prognosis for improvement.

An exam is also warranted for an unrelated problem, such as a pre-existing chronic ophthalmic disease in either eye requiring attention, or a new ophthalmic problem not related to the first cataract operation.

Q. What if the surgeon doesn’t re-examine the patient?

A. The medical necessity for surgery relies on the preceding eye exam by the surgeon. Without it, reimbursement for the second surgery is jeopardized. The Office of the Inspector General has identified potentially unnecessary cataract surgery as a serious problem.⁴

In 2015, a prepayment review found unsupported claims for cataract surgery, including second eyes. This means medical necessity for the surgery was missing or poorly documented in the prior exam.

Of course, other justifications for surgery also exist, such as the need to evaluate the retina if the view is inadequate even when the prognosis is guarded, or when the cataractous lens may be causing other morbidity. Intolerable anisometropia is also a possible reason.

Q. What CPT code(s) describes this exam?

A. There are two likely CPT codes to report an exam in the global period of the first cataract surgery; the best choice depends on the payer’s payment rates.

1. 99213-24 (EP, Low problem, Minimal data, Moderate management): When the surgeries are close together in time, and the cataract is unchanged, assessment of the problem is Low in the new E/M guidelines. Planned major surgery is Moderate management; together these support 99213.
2. 92012-24 (EP, Intermediate eye exam): Frequently, a patient is doing well in the operated eye but does not see well in the unoperated eye and complains that the eyes do not work together — a new symptom since the first surgery, supporting 92012.

Atypical situations, such as new ophthalmic disease, rapid progression of cataract, sympathetic ophthalmia or declining health necessitate a different kind of eye exam and different code(s).

Q. Is there any Medicare support for billing for the physician exam prior to second-eye surgery?

A. Yes. Under Medicare’s definition of the global surgery package, determination of the need for surgery is covered separately from the surgery itself. Medicare states: “… These services may be paid for separately: ... The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery ...”⁵ OM

REFERENCES

1. CMS.gov . Palmetto GBA Local Coverage Determination (LCD) L34413. Cataract Surgery. https://tinyurl.com/62mpeh8b . Accessed April 21, 2021.
2. American Academy of Ophthalmology. Cataract in the Adult Eye PPP – 2016. https://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp-2016 . Accessed April 21, 2021.
3. Ophthalmic Mutual Insurance Company. Cataract Surgery: Risk Management Recommendations, Version 4/6/07. https://www.omic.com/wp-content/uploads/2012/04/Cataract-Surgery-Recommendations.pdf . Accessed April 21, 2021.
4. Office of Inspector General. Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims. Dec. 22, 2014. https://oig.hhs.gov/oei/reports/oei-04-12-00281.asp . Accessed April 21, 2021.
5. CMS.gov . Medicare Claims Processing Manual, Chapter 12, §40.1B. Services Not Included In the Global Surgical Package. https://tinyurl.com/2ejm4ssp . Accessed April 21, 2021.

Suzanne L. Corcoran, COE is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .