Skip to main content
  • Savvy Coder

    Fact Sheet for Documenting the Need for Cataract Surgery

    By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement
    Add to My Bookmarks

    Download PDF

    Does your practice perform cataract surgery? To help en­sure that you meet Medicare’s pre-op documentation requirements, use this fact sheet, which is from 2021 Coding Assistant: Cataract and Anterior Segment (aao.org/codingproducts).

    When is cataract surgery deemed medically necessary? Appropriate scenarios include the following:

    • An unimpeded view of the fundus is needed for proper management of disease of the posterior segment.
    • During vitrectomy procedures if it is determined that the lens interferes with the performance of the surgery for far peripheral vitreoretinal dissection and excision of the vitreous base, as in cases of proliferative vitreoretinopathy, com­plicated retinal detachments, and severe proliferative diabetic retinopathy.
    • Lens-induced disease that threat­ens vision or ocular health, including, but not limited to, phacomorphic or phacolytic glaucoma.
    • 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). Note: If cataract extraction is performed to correct anisometropia, the medical record must substantiate the presence of significant aniseikonia secondary to anisometropia arising from the first cataract lens extraction.
    • High probability of accelerating cataract development as a result of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocyclec­tomy, or a procedure for ocular trauma) and treatments such as external beam irradiation.
    • 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 over surgery on separate dates.

    Cataract Pre-Op Checklist

    This checklist meets the current requirements of all Medicare Administrative Contractors. For commercial or Medicaid payers, check their websites.

    ▢  Chief complaint unique to each pa­tient. (Note: Don’t “clone” notes from patient to patient.)

    • Decreased ability to carry out activities of daily living, including—but not limited to—reading, watching television, driving, or meeting occu­pational or vocational expectations.

    ▢  Visual acuity (VA) and best-corrected visual acuity (BCVA).

    • At the time of press only Cigna has a VA requirement—BCVA of 20/50 or worse at distance or near (or additional testing) shows one of the following: Consensual light test­ing decreases VA by 2 lines or glare testing decreases VA by 2 lines.
    • If complaint is with near vision, document BCVA at near, too.
    • If patient complains of glare, it is appropriate to perform and document glare test results.

    ▢  Exam reveals that other eye dis­ease(s)—including, but not limited to, macular degeneration or diabetic retinopathy—is not the primary cause of decreased visual function.

    ▢  When one or more concomitant ocular diseases are present that potentially affect visual function (e.g., macular degeneration or diabetic retinopathy), the attestation should indicate that the cataract is believed to be significantly contributing to the patient’s visual impairment.

    ▢  The patient has been educated by the surgeon about the risks and benefits of cataract surgery and the alternative to surgery and has provid­ed informed consent.

    ▢  The patient has determined that he/she is no longer able to function adequately with the current visual function and desires surgery.