• Savvy Coder

    Put On Your Audit Armor, Part 2: Create Payer-Specific Checklists

    By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

    Download PDF

    The best way to audit-proof your practice is to adhere to payer-specific checklists. This month’s Savvy Coder gets you started on a checklist for cataract surgery.

    Note: According to a 2014 Office of Inspector General report, when the only diagnosis is cataract(s), Medicare does not cover testing other than one comprehensive eye examination (or a combination of brief/intermediate examinations not to exceed the charge of a comprehensive examination) plus an appropriate ultrasound scan.

    Know Your MAC’s Policies

    Under Medicare Part B, the United States is divided into several jurisdic­tions, with a Medicare Administrative Contractor (MAC) assigned to each one. These MACs can develop their own coverage policies, known as Local Cover­age Determinations (LCDs).

    Important! Go to aao.org/lcds, read the LCDs that affect your state, and in­corporate their requirements into your payer-specific checklists.

    Medicare Cataract Surgery

    Make sure that your payer-specific checklist addresses the issues below, and advise physicians not to close out a chart until all of the checklist’s require­ments have been met.

    Ensure that you have documented:

    • the patient’s chief complaint;
    • the impact that decreased vision has on activities of daily living (ADL) unique (never cloned) to each patient;
    • best-corrected visual acuity (note that most MACs don’t have a visual acuity requirement—the exceptions are CIGNA for Kentucky and Ohio, which requires “20/50 or worse,” and First Coast for Florida and Puerto Rico, which requires “worse than 20/40”);
    • physical findings of the cataract;
    • that the patient has been educated by the surgeon about the risks and benefits of surgery and the alternative to surgery, and has provided informed consent; and
    • that the patient desires surgery.

    Verify the diagnosis code. Also, be sure the surgery code is linked to a covered ICD-10 code.

    Check the indication(s) for lens re­moval. These may include the following:

    • Monocular diplopia due to a cata­ract in the affected eye.
    • Worsening angle closure due to increase in size of the crystalline lens.
    • A significant cataract in a patient who will be undergoing concurrent surgery in the same eye, such as a trabe­culectomy or a corneal transplant when the surgeon deems that the decreased morbidity of single-stage surgery is of significant benefit compared with surgery on separate dates.
    • Intolerable anisometropia or ani­seikonia uncorrectable with glasses or contact lenses that exists as a result of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity).

    Your MAC might cover lens removal in the following situations:

    • When an unimpeded view of the fundus is mandatory for proper man­agement of patients with diseases of the posterior segment of the eye(s).
    • During vitrectomy procedures if it is determined that the lens interferes with vitreoretinal dissection at the far periphery and excision of the vitre­ous base, as in cases of proliferative vitreoretinopathy, complicated retinal detachments, and severe proliferative diabetic retinopathy.

    Unique to Novitas. If your MAC is Novitas, your documentation must also show the following:

    • The patient has undergone the Pre-Cataract Surgery Visual Functioning Index (VF-8R) questionnaire. The questionnaire must be maintained in the patient’s medical records and be available upon request. (VF-8R is avail­able at aao.org/practice-management/coding/updates-resources.)
    • The length of time between the exam to determine the need for surgery and the surgical date isn’t more than 90 days.

    Is Novitas your MAC? Novitas is the MAC for the District of Columbia and for the following states: Arkansas, Col­orado, Delaware, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, Pennsylvania, and Texas.

    Further Resources

    You receive a request for records: Do you have a protocol to guide your response? If not, read “Put On Your Audit Armor, Part 1” (Savvy Coder, January 2018) for guidance on creating a written protocol.

    Make sure your documentation is sound. Read “How to Document the Need for Cataract Surgery” (Savvy Coder, July 2017).

    Use the web Audit Toolkit (Academy and AAOE member benefit). Use this online resource to learn about 1) the types of Medicare audit, 2) the focus of each type of audit, and 3) resources to help you proactively prepare and defend your documentation.

    Order the Audit Survival Toolkit webinar (product # 01250098U). Learn how to 1) identify and rectify areas in your documentation and claim submission process that make you vulnerable to audits; 2) respond to requests for records swiftly and effectively; 3) establish and improve protocols; and 4) train staff on audit preparedness.

    Order the 2019 Coding: Coding Audit Success Toolkit (product # 120444V). If you found September’s Savvy Coder helpful for your compliance, consider ordering this valuable workbook. For each type of audit, you’ll have a checklist for each item that is likely to be targeted. If you are attending AAO 2018, visit the Resource Center to review this and the Academy’s other coding tools.