Are you an outlier for cataract surgery and related services? Facilitated by the contractor RELI group, the Centers for Medicare & Medicaid Services has issued a comparative billing report (CBR) on Medicare Part B claims from Jan. 1 to Dec. 31, 2019 for these three key metrics:

1. Percent of cataract surgeries billed as a complex procedure (CPT 66982)
2. Percent of YAG procedures (CPT code 66821) performed within 18 months of cataract surgery in the same eye
3. Co-management — Percent of cataract surgeries where post-operative care was rendered by a different provider

The criteria for receiving this cataract comparative billing report (CBR202208) are that a provider: 

• Is significantly higher compared with either peer group or national percentages, in any of the three metric calculations (i.e., greater than or equal to the 90th percentile)
• Has at least 30 total beneficiaries with claims submitted for cataract surgery
• Has at least $30,000 in total allowed charges for cataract surgery

If you are the recipient of a comparative billing report, your values are compared to your state peer group values and to the national values. Nationally there are 10,019 providers that are listed as rendering providers on claims for cataract surgery services with a total allowed charges for these claims at over $1.09 billion during the 2019 calendar year. The national values for the key metrics are found in the table below:

CBR Metric	National Percentage
Percent of cataract surgeries billed as a complex procedure	8.58%
Percent of YAG procedures performed within 18 months of cataract surgery	9.44%
Percent of cataract surgeries where post-operative care was rendered by a different provider	22.36%

You can access your comparative billing report for your practice. It is an educational tool that can be used for internal provider compliance by drawing your attention to your individual utilization of specific clinical services. 

Cataract surgery continues to be a “vulnerability for improper payments”. According to the 2021 Medicare Fee-for-Service Supplemental Improper Payment Data report:

• Cataract surgery is 12th on the list of the top 20 procedures for highest improper payments
• There is a 12.7% improper payment rate for eye procedures-cataract removal/lens insertion, which represents over $218 million in improper payments 
  • 87.2% of this improper payment rate is attributed to insufficient documentation 
  • 12.8% of this improper payment rate is attributed to incorrect coding

The Academy supports the comparative billing report recommendations to reduce the possibility of improper payments found at CBR202208: Cataract Surgery Guidance and Considerations. They include:

• Perform internal compliance reviews of cataract surgery, complex cataract surgery and YAG laser procedures with attention to supporting documentation and correct coding.
• Review the encounter documentation and choose the code carefully according to the service provided to the patient and the services documented in the encounter.
• Review documentation and code selection on a recurring schedule to ensure accuracy.

Academy tools and resources are available to help you successfully meet these recommendations.

Solutions

• Engage Academy consultation services for targeting external chart audits and cataract documentation reviews.
  
  
• Accurately code tests and segment surgical procedures using the 2022 Coding Assistant: Cataract and Anterior Segment
  
  
• Ultimate Documentation Compliance Training for Scribes and Technicians is the comprehensive online course that transforms practice staff into a “compliance shield.”

Further Resources

• Find current cataract requirements for your Medicare administrative contractors at www.aao.org/lcds
  
  
• Cataract Surgeries Can Be Complex, Coding Doesn’t Have to Be - American Academy of Ophthalmology (aao.org)

• Determining the Need for YAG Laser Capsulotomy - American Academy of Ophthalmology (aao.org)

• 5 Co-management Coding Tips - American Academy of Ophthalmology (aao.org)

• Ask the Coding Experts: What to Do When Receiving a Comparative Billing Report
   
• Fact Sheet for Documenting the Need for Cataract Surgery
  
  
• Cataract Controversies — Answers to Contentious Coding Questions
  
  
• Video: Cataract Documentation Checklist
  
  
• Video: Survive and Thrive: How the Academy Helped Us Successfully Pass a Cataract TPE Audit — An Interview With Julia Lee, JD