0002 - Cataract Removal: Medical Necessity and Documentation Requirements

Issue Name
0002 - Cataract Removal: Medical Necessity and Documentation Requirements
Date
Review Type
Complex
Provider Type
Ambulatory Surgical Center (ASC); Outpatient Hospital
MAC Jurisdiction
J6, J15, JE, JF, JH, JJ, JK, JL, JM, JN

Description

Documentation will be reviewed to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.

Affected Code(s)

66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, 66987, 66988

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4.    42 CFR §405.986- Good Cause for Reopening  
5.    Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10- Anesthesia and Pain Management, §10.1- Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery; Effective 10/03/2003; Revised 02/15/2019
6.    Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10 Anesthesia and Pain Management, §80- Eye, §80.10- Phaco-Emulsification Procedure - Cataract Extraction Effective 10/03/03; Revised 02/15/2019
7.    Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10 Anesthesia and Pain Management, §80- Eye, §80.12- Intraocular Lenses (IOLs), Effective 10/03/2003; Revised 02/15/2019
8.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
9.    CGS LCD L33954- Cataract Extraction; Effective 10/01/2015; Revised 12/24/20
10.    NGS LCD L33558- Cataract Extraction; Effective 10/1/2015; Revised 09/19/2019
11.    Noridian LCD L34203- Cataract Surgery in Adults; Effective 10/01/2015; Revised 10/01/19
12.    Noridian LCD L37027- Cataract Surgery in Adults; Effective 10/10/2017; Revised 10/01/2019;
13.    Palmetto LCD L34413- Cataract Surgery; Effective 10/01/2015; Revised 10/10/19
14.    Palmetto LCA A53047- Complex Cataract Surgery: Appropriate Use and Documentation; Effective 10/01/2015; Revised 01/01/2020
15.    Novitas LCD L35091- Cataract Extraction (including Complex Cataract Surgery), Effective 10/01/2015; Revised 07/11/21
16.    First Coast LCD L33808- Cataract Extraction; Effective 10/01/2015; Retired 10/29/2019
17.    Cahaba LCD L34287- Cataract Extraction; Effective 10/01/2015, PART B ONLY; Retired 02/25/2018
18.    NGS LCA A56544- Cataract Extraction; Effective 08/01/2019; Revised 01/01/2020
19.    Noridian LCA A57195 Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised 01/01/2020