Payers Focusing on Second Cataract Surgery Documentation

Corcoran Consulting Group has become aware of increased scrutiny on the part of payers focusing on the medical necessity for “second eye” cataract surgeries. Corcoran has seen payers withhold payment for second eye surgery until documentation is provided. We have also seen attempts to recoup monies paid in the past for second eye cataract surgery when documentation is lacking. This is occurring with Medicare and non-Medicare payers.

Each eye must be appropriately documented to have a need for surgery. Many practices do a good job of documenting patient complaints related to Activities of Daily Living (ADL) for the first eye cataract surgery. Remember that ADL’s are normally listed as the very first requirement to justify medical necessity for cataract surgery. Other payer requirements are usually related to the level of vision (including glare, if a complaint exists) and other factors.

Once the patient is doing well on the first eye, payers will want to know that a complaint related to the unoperated eye still exists. Each eye needs to be separately justified in order for the claims to be supported. Do not assume that your documentation prior to the first eye surgery is adequate to support the second eye’s need for surgery; it is not. Revisit the unoperated eye’s issues with the patient to see if they remain. When they do – or have worsened – note them and be sure to indicate the eye. Establish a mindset in your practice that a case for the second eye has not been medically justified without this documentation. If a form was used before the first eye surgery to document complaints, use another form for the second eye – but note on the form which eye is being surveyed and the date of the interview.

Vigilance and careful attention to detail are your defense if questioned. Corcoran Consulting Group can help. Not only do we perform chart reviews, we can also provide training to your staff on proper documentation. Contact us via phone during business hours or at any time via our website.

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