Cataract Removal & Lens Insertion

physician looking through a large scope at patients eyes

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What’s Changed?

We updated the improper payment rate for the 2024 reporting period.

Affected Providers

Physicians or suppliers who bill for cataract removal and lens insertion eye procedures.

HCPCS & CPT Codes

Article: Billing and Coding: Cataract Extraction has the current HCPCS and CPT codes. Select your Medicare Administrative Contractor’s (MAC’s) article from the search results.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for cataract removal and lens insertion eye procedures is 14.4%, with a projected improper payment amount of $296.7 million.

You must meet the provisions in Local Coverage Determination (LCD): Cataract Extraction. Select your MAC’s LCD from the search results.

Cataract surgery with an intraocular lens (IOL) implant is a high-volume Medicare procedure.

Denial Reasons

Insufficient documentation accounted for 90.6% of improper payments for cataract services during the 2024 reporting period, while no documentation (8.5%), incorrect coding (0.3%), and other errors (0.6%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

Pre-Surgery Evaluations

The surgeon may conduct several pre-operative tests. In most cases, a comprehensive eye exam (ocular history and ocular exam) and a single scan to find the pseudophakic power of the IOL are sufficient.

In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used. For patients with a dense cataract, an ultrasound B-scan may be used.
Where the only diagnosis is cataracts, we don’t routinely cover testing other than 1 comprehensive eye exam (or a combination of a brief or intermediate exam not to exceed the charge of a comprehensive exam) and an A-scan or, if medically justified, a B-scan.
We deny claims for more tests as not reasonable and necessary unless the medical need for more tests is fully documented due to another diagnosis.

Note:
Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later or have a physician other than the diagnosing physician do the surgery. In these situations, it may be medically appropriate for the operating physician to conduct another exam. These tests are covered to the extent they’re considered reasonable and necessary by the MAC’s medical review staff.

Note:

Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later or have a physician other than the diagnosing physician do the surgery. In these situations, it may be medically appropriate for the operating physician to conduct another exam. These tests are covered to the extent they’re considered reasonable and necessary by the MAC’s medical review staff.

Additional Resources

Disclaimers

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