Awareness : Did You Know?

Did You Know? Weekly Educational Series #8

For the Week of February 27, 2017-Ophthalmology

How to avoid 2017 cataract claim hot spots by amping up your documentation.

More and more MAC’s are conducting pre-payment reviews of claims and it is important to measure your claims against certain documentation pitfalls. On their pre-payment review radar are four claims against certain documentation errors that could land your ophthalmology practice in hot water before you get reimbursed.

  • No evidence of patient’s best corrected Snellen visual acuity (BCVA) present in the record.
  • No evidence of patient-reported impairment of visual function resulting of activities of daily living.
  • Absence of a signed note or report.
  • Lack of documentation indicating the patient desires surgical correction, has received explanation risks/alternatives, and that the expected outcome will significantly improve visual and function status.

These four points of documentation are necessary for all cataract surgeries to support medical necessity and additional documentation is needed to support an anticipated complex cataract surgery. Be aware of potential errors since its been more than a year that HHS OIG has released a study stating that many ophthalmology practices/facilities were improperly upcoding cataract claims as “complex” and submitting a 66982 CPT code.

Over the past year, some coders have been reluctant to bill 66982 (extracapsular cataract removal with insertion of intraocular lens prosthesis [1-stage procedure], manual or mechanical technique [e,g., irrigation and aspiration or phacoemulsification], complex, requiring devices or techniques not generally used in routine cataract surgery [e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis] or performed on patients in the amblyogenic developmental stage) even when the code is appropriate.

The key, as always, is to support your code choice with proper documentation, and referring to these four questions to help determine if a cataract is actually complex, or if you’re in dangerous upcoding territory.

  • Does the pupil require dilation manually or using special instruments?
  • Does the IOL need the support of a capsular tension or intraocular sutures?
  • Is this a pediatrics case that includes IOL implantation?
  • Does the cataract require dye (Trypan Blue or Indocyanine Green)?

Some practices make a habit of coding every cataract surgery where dye was used to stain the capsule as “complex.” The use of the dye does not always meet the 66982 requirements. Sometimes its just and additional surgical step. Some other examples of procedures that are not necessarily “complex” are.

  • A case that takes longer than usual (i.e. if more phaco time is required)
  • Many cases that require an anterior vitrectomy (planned or unplanned)
  • Implantation of toric or mulitfocal lens, as opposed to a standard one.

The following surgeries are more likely to be considered “complex”:

  • The majority of pediatrics cases
  • A case that requires manual dilation of the pupil
  • A case requiring manipulation of a capsular tension ring

The surgeons operative report should clearly state the reason why the surgery qualifies as “complex,” but the best way to indicate complexity on the claim is to use the appropriate ICD-10 code(s). Medicare LCD’s list a variety of diagnosis codes that justify 66982, so check with your local MAC for the most up-to-date specifics.