SEP 22, 2022
CMS Releases Comparative Billing Reports on Cataract surgery
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:
- Percent of cataract surgeries billed as a complex procedure (CPT 66982)
- Percent of YAG procedures (CPT code 66821) performed within 18 months of cataract surgery in the same eye
- 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:
Percent of cataract surgeries billed as a complex procedure
Percent of YAG procedures performed within 18 months of cataract surgery
Percent of cataract surgeries where post-operative care was rendered by a different provider
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
- 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 reportrecommendations 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.