Cataract Reimbursement Revisited
Keeping current with Medicare Guidelines is easier than you think. Here's what you need to know.
By Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O., and Mary Pat Johnson, C.O.M.T., C.P.C., C.O.E.

Cataract surgery may be a common procedure in your practice, but associated coding, charting and reimbursement issues are hardly routine. As new technologies are introduced and regulations change from year to year, you can't assume established documentation and billing procedures are adequate or up-to-date.

In this article, we review current reimbursement criteria and procedures. Along the way, we highlight challenges and controversies that complicate reimbursement for cataract surgery.

Vital Statistics

In 2003, Medicare paid $51.6 billion for physician services. Ophthalmologists received nearly $3.6 billion (7%) of that total, about $1 billion of which comprised payments to surgeons for cataract surgery.

As "Cataract Surgery Volume" shows, the number of cataract procedures and consequent total dollar expenditures has increased steadily over the past three decades. This trend is expected to accelerate as the U.S. population continues to age.

Responding to this trend, Medicare closely monitors and scrutinizes all aspects of cataract surgery, a practice that has prompted frequent per-procedure

payment reductions. "Physician Reimbursement for Cataract Surgery" shows how the allowable Medicare Physician Fee Schedule for cataract surgery with an IOL (Current Procedural Terminology [CPT] 66984) has dropped from nearly $1,000 in 1996 to $684 in 2005. Fees for closely allied diagnostic tests, such as A-scan ultrasound and optical coherence biometry, have been stable during the same time period. Past and present reimbursement rates are compared in "Medicare Payments for A-scan."

The first step toward collecting proper reimbursement for cataract surgery is assessing if the patient meets Medicare's coverage criteria.

Cataract Surgery Volume	Physician Reimbursement for Cataract Surgery

Medicare Coverage Policy

In 1993, the Agency for Health Care Policy and Research (AHCPR), a division of the Public Health Service of the United States Department of Health and Human Services (HHS), published guidelines for cataract surgery. The guidelines are available at http://www.ascrs.org/eye/ptguide.html. In 2001, the American Academy of Ophthalmology published a Preferred Practice Pattern (PPP) guideline identifying characteristics and components of quality eye care. Finally, some individual Medicare carriers have published eligibility policies that incorporate many of the principles expounded by AHCPR and PPP. Although these guidelines vary among Medicare carriers, cataract surgery policies typically include:

► Diagnosis. Objective evidence must show the cataract is present and impairs the patient's vision.

► Poor vision. The patient's Snellen best-corrected visual acuity (BCVA) must be 20/50 or worse. He's also eligible for surgery if his BCVA is 20/40 or better and he has significant difficulty with glare. Complaints of glare should be confirmed by brightness acuity testing or another suitable diagnostic test.

► Dysfunction. Limited vision affects the patient's ability to perform activities of daily living, such as working, reading, driving, participating in sports or caring for himself.

► Prognosis. Cataract removal likely will restore vision and allow the patient to resume activities of daily living. An exception is made when cataract surgery is performed primarily to permit better view of the posterior segment for retinal evaluation or surgery.

► Health. The patient should be able to withstand the stress of cataract surgery and associated anesthesia.

► Awareness. The patient can appreciate the proposed surgery.

Check your local Medicare carrier's requirements before submitting claims. Deviating from your carrier's coverage policy can result in delayed payment at best and no payment at worst. (Read more about filing claims in "Examining the Second Eye.")

To receive reimbursement for the second procedure, you must document that the second cataract meets the same eligibility criteria as the first.

Once you determine the patient's condition meets the necessary coverage criteria, you can schedule him for a preoperative work-up.

Preoperative Testing

Medicare's Coverage Issues Manual (CIM) §35-44 describes the national policy on preoperative evaluation and testing before cataract surgery. It states:

In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used. For patients with dense cataracts, ultrasound B-scan may be used. Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan.

Cataract evaluation rarely requires additional preoperative tests, so Medicare expects beneficiaries to pay out-of-pocket for supplementary diagnostic tests. For example, the upstate New York Medicare carrier doesn't consider fundus photography, fluorescein angiography, electrophysiology, color vision testing or slit lamp photography necessary for standard cataract evaluation. In special circumstances, they allow B-scan ultrasound for patients with dense cataract that prevent visualization of the posterior segment of the eye. Comorbidity of the cornea, such as corneal dystrophy or corneal degeneration, supports preoperative testing with endothelial specular microscopy, however the frequency of this type of diagnostic evaluation is very low (approximately 4 times per 100 cataract surgeries within the Medicare population).

Preoperative Exam

Prior to any major ophthalmic surgery, the surgeon must carefully evaluate the patient and provide informed consent before making the decision for surgery. Under Medicare's global surgery rules, preoperative examinations are reimbursed separately from the surgery. This concept, which is outlined in CIM §35-44, also applies to cataract surgery, but the phrase "comprehensive eye exam" introduces ambiguity. CPT lists five codes for comprehensive eye examinations: 99205, 99204, 99215, 92004 and 99214. Six comprehensive consultation codes also are relevant: 99245, 99244, 99255, 99254, 99275 and 99274. Reimbursement claims for preoperative evaluations should document completion of a comprehensive history and exam, and include appropriate CPT codes.

In group practices, cataract patients may be evaluated by more than one practitioner, starting with an optometrist or a medical ophthalmologist and finishing with a surgeon. When multiple preoperative examinations are performed on the same day, practitioners should follow the guidelines as stated in Medicare Carrier Policy Manual Chapter (MCPM Ch.) 12 §30.6.5:

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day, to the same patient, by the same physician or physicians of the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.

Medicare considers optometry and ophthalmology different specialties. All ophthalmologists, including those with subspecialty training, are considered members of the same specialty.

Some Medicare carriers have published local policies that make it difficult, but not impossible, to receive reimbursement for a second-eye exam performed during the postoperative period of the first cataract surgery. Legitimate reasons that merit reimbursement include:

► Second surgery more than 90 days after the first procedure

► New symptoms in the second eye

► Significant change in health requiring new evaluation prior to proceeding with surgery.

How you record the surgical plan in the patient's chart also can affect your chances of reimbursement. Carriers who see, "Plan cataract surgery with IOL, OU, OD first" on a patient's chart won't recognize the merits of a second eye evaluation and probably will deny your reimbursement claim. This documentation indicates that the need for surgery in both eyes has already been established.

Preoperative Biometry

An important part of the preoperative exam is calculating appropriate IOL powers. Traditionally, surgeons determine axial length and IOL power with A-scan ultrasound, but they now have a second option. Optical coherence biometry (OCB) uses partially coherent light to determine total axial length and measure corneal curvature. Although OCB provides accurate results for most patients, it can be unreliable in patients with hypermature cataracts, hazy corneas or vitreous opacities.

Some surgeons choose the biometric method that fits each patient best, whereas others use both to verify accuracy. Since A-scan ultrasound and OCB provide the same information, Medicare will reimburse only one of them, presumably the test you determine has the greatest utility. In addition,

billing for either type of biometry must follow a specific format. The technical component of each test is considered bilateral and can be billed only once, while the professional component, or interpretation, is billed separately for each eye. For example:

After examining a 70-year-old woman, a surgeon plans cataract surgery on her right eye. He measures both eyes with A-scan biometry, but calculates IOL power for the right eye only. His Medicare claim should state:

76519-RT A-scan with IOL calculation, OU.

Alternately, some carriers may ask for a detailed breakdown, such as:

76519-TC A-scan, technical component

76519-26RT A-scan interpretation, right eye

This detailed claim is financially equivalent to global service (76519).

Two months later, the surgeon reexamines the same patient and schedules cataract surgery for her left eye. He uses the previous A-scan measurement in the chart to calculate proper IOL power for her left eye. The Medicare claim for this procedure should state:

76519-26LT A-scan interpretation, OS.

The introduction of OCB is an example of how Medicare guidelines adapt to changing technologies.

Postoperative Care

According to Medicare's global surgery billing policy, surgeons receive a single fixed payment for routine cataract surgery and IOL implantation (66984). (See "Coding Complex Procedures" for alternate cataract surgery codes.) This payment covers preoperative services, the surgery and all in-office care provided during the 90-day global postoperative period.

In certain cases, you may submit claims for additional procedures or examinations performed during the global period if you include the correct modifiers. However, use caution when submitting claims for "unrelated" office visits using modifier -24. Post-payment reviews show some practitioners have used this modifier inappropriately to gain reimbursement for routine postoperative care that was covered by the global surgery package. In 2004, the Office of the Inspector General issued a warning to physicians that misuse of this modifier could result in monetary penalties.

Coding for Surgical Complications

Cataract surgery usually has a low complication rate, but occasionally patients require additional care during the postoperative period. For reimbursement purposes, all office-based, complication-related, postoperative services are considered part of regular postoperative care, even if another physician in your group treats the patient.

Medicare policy states:

When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group. The provider who performs the surgery is shown as the performing physician. (MCPM Ch. 12 §40.2A2)

For example, if a patient develops cystoid macular edema (CME) after cataract surgery and you refer him to a retina specialist in your group practice, the practice can't claim additional reimbursement for the specialist's exam during the postoperative period. Medicare will reimburse the practice for medically necessary diagnostic tests, such as fluorescein angiography, but not for the complication-related office examination.

Medicare guidelines preventing specialists from filing for separate reimbursement are a concern for practices in which retina specialists frequently evaluate postoperative CME. Practice managers should consider creating an internal payment mechanism to redistribute income between the surgeon and the retina specialist.

Improve Your Reimbursement Record

As an acknowledged mainstay of ophthalmic surgery, cataract extraction will continue to receive attention from payers and policy-makers. Practices that fail to follow Medicare regulations can lose sig- nificant revenue over time. These practices also risk attracting unwanted punitive attention when they engage in creative or aggressive billing techniques.

With continued vigilance, you can improve your practice's coding compliance. First, don't overlook cataract surgery in your efforts to improve compliance. Second, try stay current with documentation and billing changes. Third, train and retrain staff as guidelines change to ensure everyone is up-to-date on Medicare coding procedures. Finally, monitor coding compliance by scheduling chart reviews at regular intervals.