Medicare covers procedures to screen for, diagnose, evaluate and treat many eye conditions. However, one of the eye conditions for which Medicare pays for most often each year is cataracts.
In an Office of the Inspector General (OIG) report, titled “Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims," Medicare is described as having paid approximately $3.5 billion in 2012 for services that screen for, diagnose, evaluate, or treat cataracts, the leading cause of blindness in the world. Medicare covers many services that diagnose or evaluate cataracts. However, Medicare has a national requirement stating that it will not routinely cover more than one comprehensive eye examination and scan for beneficiaries whose only diagnosis is cataracts.
Vulnerabilities were found in Medicare payments for ophthalmology services both in regards to the payment of an additional cataract diagnostic test as well as payment for cataract surgeries for the same eye in the same year.
Medicare covers cataract surgeries for the treatment of cataracts. Cataract surgeries remove the poorly functioning natural lens of an eye and replace it with a synthetic lens. It is medically impossible to perform more than one cataract surgery on the same eye because an eye’s natural lens will never grow back. Medically impossible services, such as this, should be denied as not being reasonable and necessary.
CPT code 66982 is the extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), and complex, requiring devices or techniques not generally used in routine cataract surgery.
CPT code 66983 is the intra-capsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure).
Palmetto GBA is currently reviewing CPT code 66984, extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification).
A cataract is defined as an opacity or loss of optical clarity of the crystalline lens. Cataract development follows a continuum extending from minimal changes in the crystalline lens to the extreme stage of total opacity. Cataracts may be due to a variety of causes. Age-related cataract (senile cataract) is the most common type found in adults. Other types are pediatric (both congenital and acquired), traumatic, toxic and secondary (meaning the result of another disease process) cataract.
Most cataracts are not visible to the naked eye until they become dense enough (mature or hypermature) to cause blindness. However, a cataract at any stage of development can be observed through a sufficiently dilated pupil using a slit lamp biomicroscope. In settings where this instrument is unavailable (e.g., skilled nursing facility), a direct ophthalmoscope can be used to assess the degree to which the fundus reflectivity (red reflex) is impaired by the ocular media. There is no scientifically proven medical treatment for cataracts.
In general, cataract surgery is performed to alleviate visual impairments attributable to lens opacity. There are uncommon situations when lens extraction becomes medically necessary for anatomic rather than optical reasons. These include lens induced angle closure (microspherophakia) and lens subluxation (Marfan syndrome).
In other situations, cataract extraction might be medically indicated with relatively less opacity because of intolerable optical imbalance. Most commonly, this would be due to surgically induced anisometropia (a significant difference in refractive errors between the eyes) or aniseikonia (a difference in magnification as a result of prior lens extraction in the one eye).
Some patients may elect lens removal and replacement primarily for refractive benefits to reduce their dependence on spectacles. Such elective procedures are not medically necessary and are called "refractive lens exchanges" to distinguish them from medically indicated cataract surgery.
Finally, advanced cataracts may need to be removed to properly visualize, treat and monitor retinal disease apart from the patient’s visual symptoms and potential.
Although not required, Palmetto GBA encourages providers to use the framework of the International Classification of Functioning, Disability, and Health (ICF) to organize the information related to relevant structural/functional impairments, activity limitations and/or participation restrictions, and any environmental factors influencing the decision to recommend cataract surgery.
Medical necessity for cataract surgery is not based solely on the presence of opacity in the lens(es). Lens extraction is considered medically necessary and therefore covered by Medicare when one (or more) of the following conditions or circumstances exists:
- Cataract causing symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function not correctable with a tolerable change in glasses or contact lenses, lighting, or non-operative means resulting in specific activity limitations and/or participation restrictions including, but not limited to, reading, viewing television, driving, or meeting vocational or recreational needs
- Concomitant intraocular disease (e.g., diabetic retinopathy, or intraocular tumor) requiring monitoring or treatment that is prevented by the presence of cataract
- Lens-induced disease threatening vision or ocular health (including, but not limited to, phacomorphic or phacolytic glaucoma)
- High probability of accelerating cataract development as a result of a concomitant or subsequent procedure (e.g., pars plana vitrectomy, iridocyclectomy, procedure for ocular trauma) and treatments such as external beam irradiation
- Cataract interfering with the performance of vitreoretinal surgery
- Intolerable anisometropia or aniseikonia, uncorrectable with glasses or contact lenses, exists as a result of lens extraction in the first eye (despite satisfactorily corrected monocular visual acuity)
Medicare will consider coverage of cataract surgery for circumstances not listed above. Coverage is based on documentation that supports medical necessity and is compatible with the accepted standards of medical care. Medicare coverage extends only to standard non-correcting prosthetic lenses. There are no CMS approved new technology intraocular lenses (NTIOLS) at this time.
The Snellen chart is frequently used as a screening tool to measure visual acuity. However, testing using high contrast letters viewed in dark room conditions can underestimate the functional impairments caused by some cataracts in common real-life situations (e.g., glare conditions, poor contrast environments, reading, halos and starbursts at night, and impaired optical quality causing monocular diplopia and ghosting).
An evaluation of visual acuity alone can neither rule in nor rule out the need for surgery. Visual acuity should be recorded and considered in the context of the patient’s visual impairment and other ocular findings.
Surgery is generally not performed in both eyes during the same surgical session because of the potential for bilateral visual loss.
In the more common situation, where surgery is performed sequentially on separate days for bilateral visually symptomatic cataracts, the appropriate interval between the first-eye surgery and second-eye surgery is influenced by several factors as noted in the local coverage determination (LCD) 34413.
- Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims (PDF, 535 KB)
- Cataract Surgery Local Coverage Determination
- Medicare Vision Services (PDF, 1.13 MB)
- National Coverage Determination (NCD) for Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery (10.1)
- New Technology Intraocular Lenses (NTIOLS) CMS web page