Cataract Services Decision Tree
This set of questions will assist with review of documentation requirements:
1. Does all documentation meet signature requirements and include the name, signature and credentials of the person performing the service?
2. Does documentation support the modifier billed? RT-right, LT-left, 50-bilateral
Yes No
3. Which Cataract Service Code is being administered and billed?
66984
66982
66821
4. Is the provider specialty 18 ophthalmology or (KY) 41 Optometrist?
5. Medical history and physical examination completed and documented prior to surgery?
Yes No
6. Is a comprehensive ophthalomologic exam present?
Yes No
7. Is an operative report present?
Yes No
8. Is there an ophthalmic biometry?
Yes No
9. Does the documentation support the procedure billed as medically necessary?
Yes No
- Local Coverage Determination (LCD): Cataract Extraction (L33954)
- Medicare National Coverage Determinations Manual Chapter 1, Part 1 (Sections 10 – 80.12) Coverage Determinations
- Medicare Claims Processing Manual Chapter 14 - Ambulatory Surgical Centers
- Local Coverage Article: Billing and Coding: Cataract Extraction (A56453)
Physician documentation specifying rationale
4. Is the provider specialty 18 Ophthalmology or (KY) 41 Optometrist?
5. Does documentation support the required diagnoses are present (primary and secondary codes, if applicable)?
Yes No
6. Medical history and physical examination completed and documented prior to surgery?
Yes No
7. Is a comprehensive ophthalomologic exam present?
Yes No
8. Is an operative report present?
Yes No
9. Is there an ophthalmic biometry?
Yes No
10. The patient has impairment of visual function due to cataract(s) and all of the following criteria are met and clearly documented:
- Decreased ability to carry out activities of daily living
- Patient has a best corrected visual acuity of 20/50 or worse at distant or near; or additional testing shows either consensual light testing decreases visual acuity by two lines or glare testing decreases visual acuity by two lines
- The record reflects that the cataract is the primary cause of decreased visual acuity and/or functional impairment; other diseases have been ruled out. OR there is documentation of phacomorphic or phacolytic glaucoma. OR there is documentation that the cataract obscures an adequate view of the fundus which is necessary for monitoring and/or treatment of diseases of the posterior segment of the eye
Yes No
11. Does the documentation support the extraordinary work performed during interoperative or postoperative periods in a subset of cataract operations including:
- Miotic pupil which will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye and which requires the insertion of 4 iris retractors through 4 additional incisions.
- The presence of a disease state that produces lens support structures that are abnormally weak or absent. This requires the need to support the lens implant with permanent intraocular sutures and/or a capsular support ring may be necessary to allow placement of an intraocular lens.
Yes No
- Local Coverage Determination (LCD): Cataract Extraction (L33954)
- Medicare National Coverage Determinations Manual Chapter 1, Part 1 (Sections 10 – 80.12) Coverage Determinations
- Medicare Claims Processing Manual Chapter 14 - Ambulatory Surgical Centers
- Local Coverage Article: Billing and Coding: Cataract Extraction (A56453)
4. Is the documentation for the procedure 90 days after the cataract surgery?
5. Is the documentation showing the procedure done less than 90 days after the cataract surgery?
Yes No
6. Does the documentation show medical necessity if the capsulotomy is performed more than once on the same time, or a separate episode of care, the rationale and indication are clear?
Yes No
There must be clear documentation in the medica record showing significant visual debility, preoperative uveitis, chronic glaucoma, diabetic mellitus or prolonged use of pilocarpine hydrochloride.
- Medicare National Coverage Determinations Manual Chapter 1, Part 1 (Sections 10 – 80.12) Coverage Determinations
- Medicare Claims Processing Manual Chapter 14 - Ambulatory Surgical Centers
- Local Coverage Determination (LCD): Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy (L33946)
- Local Coverage Article: Billing and Coding: Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy (A56493)