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
Palmetto and WPS only- 66989, 66991
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 §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 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
6. 42 CFR §405.986- Good Cause for Reopening
7. 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
8. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §80- Eye, §80.10- Phaco-Emulsification Procedure - Cataract Extraction; §80.12- Intraocular Lenses (IOLs)
9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
10. CGS LCD L33954- Cataract Extraction; Effective 10/01/2015; Revised 01/04/2024
11. CGS LCA A56453- Billing and Coding: Cataract Extraction; Effective 10/01/2016; Revised 01/04/2024
12. NGS LCD L33558- Cataract Extraction; Effective 10/1/2015; Revised 09/19/2019
13. NGS LCA A56544- Billing and Coding: Cataract Extraction; Effective 08/01/2019; Revised 01/01/2024
14. Noridian LCD L34203- Cataract Surgery in Adults; Effective 10/01/2015; Revised 07/30/2023
15. Noridian LCD L37027- Cataract Surgery in Adults; Effective 10/10/2017; Revised 07/30/2023
16. Noridian LCA A57195- Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised 01/01/2024
17. Noridian LCA A57196- Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised 01/01/2024
18. Palmetto LCD L34413- Cataract Surgery; Effective 10/01/2015; Revised 11/21/2024
19. Palmetto LCA A56613- Billing and Coding: Cataract Surgery; Effective 06/13/2019; Revised 04/30/2023
20. Palmetto LCA A53047- Complex Cataract Surgery: Appropriate Use and Documentation; Effective 10/01/2015; Revised 01/01/2022
21. Novitas LCD L35091- Cataract Extraction (including Complex Cataract Surgery); Effective 10/01/2015; Revised 07/11/21
22. Novitas LCA A56615- Billing and Coding: Cataract Extraction (including Complex Cataract Surgery); Effective 06/13/2019; Revised 07/11/2021
23. First Coast LCD L33808- Cataract Extraction; Effective 10/01/2015; Retired 10/29/2019
24. First Coast LCD L38926- Extraction (including Complex Cataract surgery); Effective 07/11/2021
25. First Coast LCA A58592- Cataract Extraction (including Complex Cataract Surgery); Effective 07/11/2021
26. WPS LCD L39716- Cataract Extraction; Effective 2/11/2024; Retired 10/13/2024
27. WPS LCA A59556- Billing and Coding: Cataract Extraction: Effective 2/11/2024; Retired 10/13/2024
28. WPS LCD L39905- Cataract Surgery; Effective 10/13/2024
29. WPS LCA A59805- Billing and Coding: Cataract Surgery; Effective 10/13/2024; Revised 11/14/2024
30. AMA CPT Codebook