Reimbursement guidelines are constantly evolving. One area that is becoming more challenging is the question of whether an exam is billable following first-eye cataract surgery when the decision to proceed with the second-eye surgery is made.

Q. Must the surgeon examine a patient prior to performing second-eye cataract surgery?

A. Yes, this hasn’t changed. Remember that 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. Since a good outcome of the first surgery cannot be guaranteed in advance, the surgeon needs to evaluate the patient again before the second procedure. Before the first surgery, surgeons cannot state with absolute certainty that surgery will occur in both eyes.

Although cataracts in both eyes may certainly be diagnosed initially, the surgeon needs to re-examine the patient after the first surgery to re-evaluate and obtain informed consent again. Palmetto GBA, the Medicare Administrative Contractor (MAC) for several states, publishes the following: “The patient and ophthalmologist should discuss the benefits, risks, need, and timing of second eye surgery …” and “An adequate interval of time has elapsed to evaluate and treat early postoperative complications in first eye, such as endophthalmitis.”¹

The AAO, in its Preferred Practice Patterns (PPP), Cataract in the Adult Eye (page 51), adds: “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 surgeon must obtain informed consent. Ophthalmic malpractice carrier OMIC, in its Cataract Surgery Recommendations, 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.” Also: “Obtain consent for each cataract procedure.” [Emphasis added]³

Q. What type of documentation supports a decision for second-eye surgery?

A. The AAO PPP states that no single criteria 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.

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. Is this visit billable?

A. This is where guidelines are changing. In the past, we’ve said that it generally is billable. However, we at Corcoran have had to change our advice. We now advise that the visit is sometimes billable, but not usually.

In residency, ophthalmologists learn to evaluate both eyes, and patients often meet the medical necessity for surgery in both eyes. Cataract surgery is almost always performed one-at-a-time with payer policies requiring providers to confirm the need to proceed with the second procedure. For most patients, if cataract is the only diagnosis, the exam between procedures simply confirms the patient’s complaints of reduced visual function; this is not a separately billable exam.

Q. What circumstances support a billable exam?

A. There are a number of situations that support a billable exam.

In the event of comorbidities, a separate exam may be billable. If this exam takes place within the global period for the first eye surgery, the medical record should clearly distinguish the reason for the visit as a billable, unrelated condition, not postoperative care for the initial surgery.

Palmetto’s cataract LCD supports this instruction but also states, “... this A/B MAC would consider the need for a separate service to be rare and must be justified with documentation.”

In addition, if the time period between procedures is lengthy, the surgeon must be sure that the patient’s situation has not changed or has not changed in a way to make cataract surgery unadvisable.

Q. If an exam is billable, what modifier(s) is required on the claim for the eye exam?

A. When a billable visit occurs within the postoperative period of the first cataract operation, append modifier 24 (unrelated evaluation and management service by the same physician during a postoperative period) to the CPT code for the visit. If the visit occurs on the day of surgery or the day before, use modifier 57 as well. The ICD-10 code selected must identify the unoperated eye.

Q. What are the consequences if the surgeon doesn’t examine the patient prior to second-eye surgery?

A. The medical necessity for surgery relies on an eye exam by the surgeon and the surgeon’s determination that surgery will be beneficial. Without it, reimbursement for the second surgery is jeopardized.

The OIG has identified potentially unnecessary cataract surgery as a serious problem.⁴ In 2015, Palmetto did a prepayment review that 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. CMS’ recovery audit program investigates potential improper payments, and one topic is cataract removal.⁵ OM

References

1. Palmetto GBA. Cataract Surgery. LCD # L34413. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34413 . Accessed May 25, 2022.
2. American Academy of Ophthalmology. Cataract in the adult eye Preferred Practice Pattern. Published Nov. 11, 2021. https://www.aaojournal.org/article/S0161-6420(21)00750-8/fulltext . Accessed May 25, 2022.
3. Ophthalmic Mutual Insurance Company. Cataract surgery: Risk management recommendations. www.omic.com/wp-content/uploads/2012/04/Cataract-Surgery-Recommendations.pdf . Accessed May 25, 2022.
4. Office of Inspector General. Medicare paid $22 million in 2012 for potentially inappropriate ophthalmology claims. https://oig.hhs.gov/oei/reports/oei-04-12-00281.asp . Accessed May 25, 2022.
5. Centers for Medicare & Medicaid. Approved RAC topics. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics . Accessed May 25, 2022.

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