Medicare Administrative Contractor notes “Vulnerability” related to Cataract Surgery Documentation

Date: October 15, 2019

On October 7, 2019, WPS, the Part B Medicare Administrator for regions J5 and J8, and the Part A contractor for a large number of states, published the following information under its “Claims News and Updates” recently.  They published:

“Recent data analytics show a possible vulnerability in cataract surgery. The results of this analysis indicate a need for clarification on documentation standards.”

For more in depth information, see the WPS Cataract Surgery resource.  This covers the important documentation criteria and coding information for covered cataract procedures.  This publication appears to be in response to WPS audits which likely noted weak documentation.

There are no policy changes with this update; however, it is a clear indication that WPS will continue to actively review cataract surgery claims to ensure they meet all documentation requirements.  The WPS Cataract Surgery Guide states that “documentation for cataract surgery should show that the patient is having symptoms such as blurred vision and visual distortion. Documentation should also show symptoms are affecting their lifestyle, glasses do not provide enough relief, the patient has a diagnosis of cataracts, and surgery will improve the patient’s condition. Finally, [when asked for documentation] you must include the operative report signed by the surgeon with informed consent.”

Medicare requires the choice of the procedure code that best fits the documented services.  CMS lists the services that Medicare considers covered as well as noncovered in the Medicare Vision Services fact sheet.

We are happy to assist groups and facilities with general claims issues and other coverage topics, which include: proper code selection, chart reviews and payer action questions. We provide training on these and other subjects. You can download our “App”, Corcoran 24/7 via one of the links below.

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