Cataract surgery is one of the top procedures performed in an ambulatory surgery center (ASC).1 However, the reimbursement process for this procedure faces ongoing scrutiny, highlighting the crucial need for compliance with Medicare’s payer documentation requirements.2 While cataract surgeons bear the primary responsibility for meeting documentation standards, ASCs must ensure proper documentation and compliance with payer policies to secure their reimbursement.3
This article will highlight the primary reasons for Medicare cataract surgery denials and provide actionable solutions to help ASCs improve compliance and minimize lost revenue. Remember to always identify the payer and follow their specific documentation requirements.
Understanding Reasons for Denial
Lack of medical necessity is the most common reason for denial of cataract surgery coverage. When a procedure is deemed not medically necessary based on the provided documentation, it leads to audit failures. Cataract surgery denials often originate from three primary medical necessity deficiencies: failure to meet local coverage determination (LCD) requirements, incomplete or missing documentation of a presurgical eye evaluation, and insufficient demonstration of the procedure’s impact on the patient’s activities of daily living (ADLs).
Failure to Meet LCD Requirements
For Medicare Part B patients, local coverage determination (LCD) policies outline the specific criteria
that must be met for a procedure to be considered medically necessary and eligible for reimbursement. ASCs must ensure that all documentation aligns with LCD requirements to avoid denials on this basis. This includes documenting the patient’s clinical history, diagnosis, and treatment plan in accordance with LCD guidelines.
Lack of Presurgical Eye Evaluation Documentation
A presurgery eye examination is essential for assessing the patient’s best-corrected visual acuity (BCVA), determining the presence of cataracts, and evaluating the need for surgery. Failu
re to confirm the performance of a presurgery eye examination can result in denial for lack of medical necessity. ASCs should establish protocols to ensure cataract surgeons properly document and confirm completion of a comprehensive eye examination prior to scheduling surgery.
Insufficient Demonstration of Impact on ADLs
Cataract surgery is often performed to improve a patient’s quality of life by restoring visual function and independence in daily activities. Denials occur when documentation fails to demonstrate the significant impact of the visual impairment on the patient’s ADLs. Surgeon audit failures may result in ASC facility fee recoupment due to inadequate ADL and medical necessity documentation.4
Surgery Center Solutions
To avoid medical necessity denials, ASCs can implement several proactive measures (Table 1). First, establish a requirement for cataract surgeons to provide detailed examination notes documenting the results of the presurgery eye examination. This documentation should include assessments of BCVA by manifest refraction, cataract severity, and any other relevant findings that support the need for surgery. This documentation should be included in the patient’s history and physical examination (H&P) prior to the surgery.5
In addition to clinical documentation, ASCs can incorporate patient-reported visual complaints to demonstrate the impact on ADLs. This can be accomplished by utilizing a standardized visual functioning questionnaire form like the VF-8R. This questionnaire should be used for each eye to ensure compliance with the ADL requirement.
ASCs should implement robust processes to verify the accuracy of documentation before submission. This may include conducting internal reviews or audits to ensure that all documentation aligns with the services billed. Additionally, ASCs can utilize electronic health record (EHR) systems or other technology solutions to flag potential errors and discrepancies in documentation.
Other Solutions to Consider
Discrepancies in the date of service can lead to denials if documentation does not align with the billed date. ASCs should implement measures to improve date accuracy, such as cross-referencing documentation with billing records to ensure consistency. Regular audits can also help identify and address any discrepancies in date accuracy to prevent future denials.
Timely submission of documentation is critical to supporting billed services and avoiding denials. Insufficient documentation submissions can result in denials for reasons such as no response to additional documentation requests (ADRs), incorrect eye documentation, or discrepancies in the date of service. ASCs should establish protocols to ensure that all requested documentation is submitted promptly in response to ADRs. This may involve assigning specific staff members to oversee the documentation submission process and implementing tracking systems to monitor the status of pending requests.
Upon receipt of an ADR for an audit, CMS may seek your practice’s electronic signature protocol. This demonstrates adherence to securing electronic physician signatures, ensuring the absence of shared passwords. Electronic signatures necessitate authentication, protection against misuse and alteration, and distinct recognition as electronic, distinct from typewritten signatures. The physician’s password must be robust, as the individual associated with the electronic signature is accountable for the information’s authenticity.6
Conclusion
Cataract surgery reimbursement presents unique challenges for ASCs, including navigating medical necessity requirements and ensuring documentation compliance. By understanding the top denial reasons, implementing proactive solutions, and adhering to a comprehensive checklist, ASCs can enhance compliance, minimize denials, and streamline the reimbursement process for cataract surgery. Through ongoing education, training, and collaboration with cataract surgeons, ASCs can optimize documentation practices and achieve successful reimbursement outcomes. OASC
References
1. Top 10 procedures performed at surgery centers. Definitivehc.com. Accessed May 16, 2023. https://www.definitivehc.com/resources/healthcare-insights/top-procedures-at-ascs
2. Audit Failure Keeps the Target on Cataract Extraction. American Academy of Ophthalmology. Accessed May 17, 2024. https://www.aao.org/practice-management/news-detail/audit-failure-keeps-target-on-cataract-extraction
3. American Academy of Ophthalmology. Cataract Surgery Audits Include Ambulatory Surgical Centers. May 21, 2024. Accessed June 17, 2024. https://www.aao.org/practice-management/news-detail/cataract-surgery-audits-ambulatory-surgical-center
4. Vicchrilli S. Fact Sheet for Documenting the Need for Cataract Surgery. Eyenet Magazine. January 2021. Accessed June 17, 2024. https://www.aao.org/eyenet/article/fact-sheet-documenting-need-for-cataract-surgery
5. Baugh M. Coding Complex Cataract Cases. The Ophthalmic ASC. May 2023. Accessed June 17, 2024. https://digital.ophthalmologymanagement.com/articles/coding-complex-cataract-cases
6. Centers for Medicare and Medicaid Services. Complying with Medicare Signature Requirements. MLN Fact Sheet. April 2024. Accessed June 17, 2024. https://www.cms.gov/mln905364-complying-with-medicare-signature-requirements
