Cataract surgery audits are not aimed solely at the surgeon. Targeted Probe and Educate (TPE) review of Current Procedural Terminology (CPT) codes 66984 and 66982 includes ambulatory surgical centers (ASCs).

Recent medical record reviews conducted by Noridian during the first quarter yielded a 55.12% error rate. The main errors included missing documentation requirements and failure to support medical necessity for cataract surgery.

Just as surgeons must maintain a copy of the operative report in their records, ASCs must possess the supporting documentation required by each unique payer. Ensure your ASC has:

• A chief complaint and history of present illness unique to each patient
  • A clear statement of the decreased ability to carry out specific activities of daily living including, but not limited to, reading, watching television, driving, or meeting occupational or vocational expectations
• Visual acuity and best-corrected vision by manifest refraction
• Documentation of the cataract grade
• When one or more concomitant ocular diseases are present that potentially affect visual function (e.g., macular degeneration or diabetic retinopathy), an attestation should indicate that the cataract is believed to significantly contribute to the patient’s visual impairment and removal is expected to significantly improve visual function.
• A physician assessment that a tolerable change in glasses will not improve the patient’s vision of impact on daily living and that surgery is recommended
• Documentation that the patient has been educated by the surgeon about the risks and benefits of cataract surgery and the alternative to surgery, informed consent and desires to proceed with surgery
• Documentation of a physician’s surgical order

Visit the Academy’s Cataract Surgery Documentation hub for additional resources.