Medicare Reimbursement for Exam Prior to Second Cataract Surgery

The evaluation before the first cataract operation does not establish the need for the second operation.  The decision for surgery must be made prior to each procedure.  The surgeon might say, “After we finish the first operation, if all goes well, we’ll consider surgery on your other eye”.  Since the patient and the surgeon hope for a good outcome, but it cannot be guaranteed in advance, the surgeon needs to evaluate the patient a second time.  Before the first surgery, surgeons cannot state with absolute certainty that surgery will occur in both eyes.

Although cataracts in both eyes may be diagnosed initially, the surgeon needs to re-examine the patient after the first surgery to re-evaluate and obtain informed consent again.

This FAQ addresses the following:

  1. Must the surgeon examine a patient prior to performing second-eye cataract surgery?
  2. Is a surgeon able to determine the need for second-eye cataract surgery prior to the first procedure?
  3. Is this visit eligible for reimbursement during the postoperative period of the first surgery?
  4. Is there any guidance from Medicare supporting billing for the physician evaluation prior to second-eye surgery?
  5. What type of documentation supports a decision for second eye surgery?
  6. What modifier or other notation is required on the office visit claim?
  7. If this exam occurs outside the global period of the first surgery, is the exam reimbursed?
  8. Are there other reasons the visit may be billable?
  9. What are the consequences if the surgeon doesn’t examine the patient prior to second eye surgery?

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