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  • Savvy Coder

    Auditproof Your Evaluations for Cataract Surgery

    By Matthew Baugh, MHA, COT, OCS, OCSR, Academy Manager of Coding and Reimbursement; David B. Glasser, MD, Academy Secretary for Federal Affairs; and Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement

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    Cataract surgery is one of the most common surgeries in ophthalmology. Consequently, it is a top audit target for all payers.

    Would your charts stand up to audit scrutiny? Noridian, the Medicare Administrative Contractor (MAC) for 13 states, recently shared results of its postpayment audits for cataract surgery. From 21% to 71% of claims would warrant denial of payment be­cause documentation did not meet the requirements of local coverage determi­nations (LCDs;

    Make your charts auditproof. If your practice performs cataract surgery, it is only a question of time before you get audited. You can start preparing for this eventuality by reviewing the following documentation requirements.

    A Unique Chief Complaint Must Impact an ADL

    When you establish the need for cata­ract surgery, documentation of a chief complaint that impacts an activity of daily living (ADL) is a fundamental re­quirement for all payers. Ask all poten­tial cataract patients about their visual symptoms and the activities they have difficulty performing. Make sure to document which eye(s) are impacted. Your documentation should be unique to the patient, so do not copy text from one patient’s record to another.

    Example. Documentation might in­clude, “New patient referred for cataract evaluation. Blurred vision in the left eye for the past year. Activity affected: diffi­culty driving and watching TV.”

    Use a VF-8R form. When completed, the nationally recognized Pre-Cataract Surgery VF-8R Patient Questionnaire (see “Use These Resources”) fulfills—for most carriers—the require­ment that you document how the chief complaint impacts a patient’s ADL.

    Visual Acuity

    All Medicare payers require that best-corrected VA (BCVA) be documented. Therefore, all cataract surgery patients should have a manifest refraction performed during the visit at which the recommendation for surgery is made. Near vision and glare testing, both with uncorrected VA and BCVA, should be performed when indicated by the chief complaint and/or the impacted activity of daily living. Some commercial carri­ers expect you to document the method of glare testing.

    Example. This documentation sam­ple shows a chart note that might meet MAC’s requirements:

    • VA: OD—SC: 20/30, CC: 20/25; OS—SC: 20/50, CC: 20/40
    • Refraction: OD—Sph: –0.50, BCVA: 20/20; OS—Sph: –1.00, Cyl: +.5, Axis: 120, BCVA: 20/40.
    • Glare (BCVA): OD: 20/40; OS: 20/80

    Note: OD = left eye; OS = right eye; SC = without correction; CC = with correction; Sph = sphere power; Cyl = cylinder power.

    Glasses aren’t an option. For all surgical cataract patients, include this key fact: a tolerable change in glasses or other visual aids does not provide satisfactory functioning vision and the patient’s lifestyle is compromised.

    Physical Examination

    Most payers require that you perform a comprehensive examination prior to cataract surgery. Comprehensive examinations include performing and documenting all 12 elements of the eye exam and documentation of the type and grade of cataract (i.e., 1-4+). Special consideration should be made to document the status of any concom­itant ocular diseases that are present and that could possibly affect the patient’s vision. You should also include a statement that the “cataract is believed to be significantly contributing to the patient’s visual impairment.”

    Example. Document all 12 exam elements, including:

    • Lens: 2+ NS OS
    • Retina: Attenuated vessels, normal macula

    Note: NS = nuclear sclerosis.

    The Assessment and Plan

    In addition to a cataract diagnosis and the recommendation and decision for cataract surgery, payers also expect you to document these two statements:

    • The patient has been educated by the surgeon about the risks, benefits, and alternatives to cataract surgery, has provided consent, and desires to proceed with surgery.
    • There is a reasonable expectation that cataract surgery will improve the patient’s visual function.

    Note: If surgery is being performed to improve visualization of the posteri­or segment or if comorbidities have the potential to limit visual recovery, this should be clearly stated. In addition, the risks, benefits, and alternatives doc­umentation should include a statement that the patient is aware of the potential for limited visual recovery and still wishes to proceed with surgery.

    Example. Documentation could include, “Nuclear Sclerosis OS. Cataract surgery recommended and expected to improve vision. Vision is not correctable by glasses or other nonsurgical mea­sures. R/B/A were discussed with the patient. These included, but are not limited to: bleeding, infection, loss of vision, loss of the eye, need for more surgery, glaucoma, retinal detachment, need for glasses, corneal edema. The patient voiced understanding and wishes to proceed. All lens options were discussed with the patient including monofocal lenses, multifocal lenses, and toric lenses. The risks and benefits of each were discussed, including halos, glare, and possible need for glasses. No guarantees about vision after surgery were given. The patient voiced under­standing and wishes to proceed.”

    Note: R = risks; B = benefits; A = alternatives.

    Under Scrutiny

    Whether it is a prior authorization, a Medicare Targeted Probe and Educate (TPE) audit, or a commercial payer audit, insurance payers are increasing their scrutiny of chart documentation that supports the medical necessity of cataract surgery. Deficiencies in doc­umentation will prompt additional reviews. Ensure that you are in com­pliance by performing internal chart audits, which can be done using the pre-op documentation checklist (see the fact sheet, listed below) along with the payer’s policy as your guides.


    1 Accessed Aug. 11, 2022.

    Use These Resources

    The American Academy of Ophthalmic Executives (AAOE) offers many tools, reference materials, and services, such as the following: