Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27479

Cataract Surgery

L27479

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Indications 

Medicare coverage for cataract extraction and cataract extraction with intraocular lens implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries who have a cataract, and who meet the following criteria:

1. The patient has undergone a standardized formal measure of his visual functional status, the results of which suggest that the patient's visual functional status can be improved commensurate with the risk of surgery by undergoing cataract extraction with intraocular lens implant. Such testing can be performed with standardized measurement tools.

2. The patient has impairment of visual function due to cataract(s) resulting in:

• Decreased ability to carry out activities of daily living such as reading, viewing television, driving or meeting occupational or vocational expectations.
• Snellen visual acuity of 20/40 or worse.
• If there is a glare component, glare testing which reduces visual acuity to less than 20/40. Special situations might arise where a patient would need better than 20/40 vision to function (pilots, professional drivers, etc.). In these instances additional documentation should be available in the patient's medical record describing these circumstances.

3. Other medical indications exist for cataract removal such as:

• Clinically significant anisometropia in the presence of a cataract.
• The lens opacity interferes with optimal diagnosis or management of posterior segment conditions.
• The lens causes inflammation (phacolysis, phacoanaphylaxis).
• The lens induces angle closure (phacomorphic, phacotopic).

4. The patient has undergone an appropriate preoperative ophthalmologic evaluation, which generally includes a comprehensive ophthalmologic exam and an A-scan ultrasound or partial coherence interferometry and keratometry or corneal topography. Other ophthalmologic studies should be reserved for special situations, such as:

• B-scan for patients with dense cataracts, which preclude visualization of the posterior segment of the eye including the vitreous and/or retina, but not limited to these.

5. In rare cases insertion of two intraocular lenses (Piggyback) at the time of the initial cataract surgery may be necessary. This can occur in cases of extreme hyperopia or microphthalmos where an intraocular lens would not provide adequate refractive power to achieve emmetropia. Documentation of the underlying condition and an explanation of the reasoning for such decision would need to be submitted with the claim.

Preoperative Ophthalmologic Evaluation and Testing

Routine pre-operative ophthalmologic screening without substantiated signs or symptoms of disease is not medically necessary. Where the only diagnosis is cataract(s), Medicare does not cover testing other than one preoperative ophthalmologic evaluation, which generally includes a comprehensive ophthalmologic examination and an A-scan ultrasound or OCB (when an IOL is planned). Pre-operative systemic evaluation is left to the discretion of the operating surgeon, anesthesiologist, and the patient's family doctor or internist.

The goals of the physical examination of a patient whose chief complaint may be related to a cataract are:

• to diagnose or confirm the presence of a cataract
• to confirm that the cataract is a significant factor related to the visual impairment and symptoms described by the patient
• to exclude or identify other ocular or systemic conditions that might contribute to the patient’s visual impairment or affect the surgical plan or ultimate outcome.

The ophthalmic examination should include the following components:

1. Patient history (including patient’s assessment of functional status
2. Snellen acuity and refraction
3. Measurement of intraocular pressure
4. Assessment of pupillary function
5. Examination of ocular motility
6. External examination
7. Slit-lamp examination
8. Dilated examination of the fundus (unless contraindicated by the anatomy of the eye)

The following tests are generally not indicated in the preoperative workup for cataract surgery. If performed, the indications for their use must be documented in the patient’s medical record:

• Contrast sensitivity testing.
• Potential vision testing.
• Formal visual fields.
• Fluorescein angiography.
• External photography.
• Corneal pachymetry/specular microscopy.
• Specialized color vision tests.
• Electrophysiologic tests.

The maximum interval between the preoperative examination and the date of surgery should be no greater than 3 months. Patients should be educated to contact the ophthalmologist if they have a change in visual symptoms during the interval between the preoperative examination and the surgery.

Contraindications 

The following are contraindications to surgery for visually impairing cataract except as noted above:

• Glasses or visual aids provide satisfactory functional vision.
• The patient’s lifestyle is not compromised by the cataract.
• The patient is unable to undergo surgery because of coexisting medical or ocular conditions.
• The patient does not desire surgery.
• Surgery will not improve visual function.
• A legal consent cannot be obtained.

Limitations 

All of the patient selection criteria outlined in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy have not been met (e.g., best corrected visual acuity of less than 20/40).

Preoperative testing performed in excess of the guidelines outlined in the “Indications and Limitations Coverage and/or Medical Necessity” section of this policy will be considered not medically necessary.

Bilateral cataract procedures performed on the same date of service will be denied, unless documentation is submitted with the claim to support the necessity of the bilateral procedure.

It is expected that more than one A-scan or OCB per year would generally not be medically necessary.

Ophthalmic biometry for lens power calculation should not be performed unless a decision to remove the cataract has been made by the patient and the surgeon. If the biometry is performed by an optometrist, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary. If biometry is repeated by the operating surgeon due to the inadequacy of the study, the original eye care physician/provider should anticipate not being reimbursed for the study.

B-scans performed without documented evidence of a dense cataract or that the cataract precluded visualization of the posterior segment of the eye including the vitreous and/or retina will be considered not medically necessary.

Surgical Services

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution: 04/01/2008

05/15/2008

05/23/2008

L27479

07/31/2008

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