There’s been a recent uptick in Medicare audits related to cataract surgery. The auditors are focusing on the coverage documents in force when you did your surgery—your Local Coverage Determinations (LCD) and Local Coverage Articles (LCA). There’s also been a general resurgence of audits, so we’ll focus on how to better support your claims with proper documentation. 

Q: I heard that some surgeons and facilities were getting audited on cataract surgery. What are these people looking for?

The actual focus varies because your actual chart documentation requirements are slightly different based on the region you’re filing claims in, but there are some commonalities. Clearly, to support your claims for cataract/IOL surgery, you’ll need a functional complaint (merely “blur” isn’t enough—you need the patient to specify for you what impact the blur has on their activities of daily living, or ADL). Some practices do this with a formal survey document that’s part of the chart, but while a couple of Medicare Administrative Contractors had a requirement for a written document in the past, it’s not an absolute for any MAC now. If this is a weak area for you, you’re in for a tough time if you’re audited, since it affects so many charts.

Q: What else should I know about these audits?

It’s clear that the auditors are strictly focusing on your LCD or LCA that was in force on the date of surgery, not as it may be now in 2022. You can’t just go to your current coverage documents; you need to get the ones they are using to see if you’re OK. In some cases the documents are the same—but not always.

For example, Noridian (the MAC in California and a number of other Western states), states the following in its LCD #L34203: “The following documentation must be present in the medical chart,” and then goes on to list six absolute requirements. The use of the word “must” is deliberate and failure to have them means you’re at high risk of having the funds recouped. Noridian is doing these cataract surgery audits as “TPE” audits, a type of review covered in our November 2021 column in Review. 

Q: Give me an example of how this might be an issue.

For example, one of the Noridian “musts” is: “A best-corrected Snellen visual acuity at distance (and near if the primary visual impairment is at near) as determined by a careful refraction under standard testing conditions as appropriate must be recorded to establish the inability to correct the patient’s visual function with a tolerable change to glasses or contact lenses. Neither uncorrected visual acuity nor corrected acuity with the patient’s current prescription will satisfy this requirement.” Having only vision with current glasses with a pinhole is inadequate. Doing a refraction but not listing the acuity with that result is every bit as weak. 

Q: If I have the above, am I still at risk?

Maybe. While you need to meet all six requirements, Noridian has two other “musts” that we see neglected more often than the others. The first is: “An attestation supported by documented symptoms and physical findings in the medical record indicating that the patient’s impairment of visual function is believed not to be correctable with a tolerable change in glasses or contact lenses.” 

Clearly, it would be best to have your EMR “smart phrase” or paper-chart note make this point for you by having it written out longhand. Don’t make the auditor try to guess how correctable the patient’s vision is by looking at the symptoms and measurements. 

The second requirement that’s often neglected is: “A statement that the patient desires surgical correction, that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that lens surgery will significantly improve both the visual and functional status of the patient.” 

Most practices have something about the patient agreeing to proceed with surgery, but they might forget the payer demands something more in a statement in your chart about how much the visual and functional status are likely to improve. Of course, not all patients improve, such as patients with bad retinal disease, for example. However, in the cases of these retinal patients, you’re doing the surgery for a different indication—to see the back of the eye when you couldn’t otherwise—and Noridian allows for that unusual situation in a separate area of the document.

Q: If I’m audited as the surgeon, is my ASC claim at risk also?

It may be if the ASC only uses your charts to document support for their separate claims. What this means is that your $600 surgeon claim issue now makes the ASC’s $1,000 (approx.) payment suspect. 

Q: What other types of Medicare audits are taking place?

The Recovery Auditors (of which there are four) and the one national Supplemental Medicare Review Contractor have also increased their oversight, and some of it affects us in eye care. Audits on Botox drug/injection billing, and intravitreal injections/drugs/modifier 25 billing are all active now. 

If you’re doing medical Botox, you should be properly billing for the drug you administer as well as the drug you don’t use (modifier JW). 

For intravitreal injections, you need the dose administered, the drug (including lot number and expiration date) and a note that you discarded the overfill (here you can’t bill for it with JW); this is important because it documents that you didn’t improperly split vials. When audits are taking place for the IV injections/drugs, they look at all services you billed on that day, which could include an exam on the same date as the minor surgery injection (via modifier 25 use).

Q: Is there anything I should know about these other (non-TPE) audit types?

Yes. In each of these, an outside entity wins a bid to do these on behalf of Medicare. They get to keep some of the proceeds but in all cases they must use your local policy on the date of the service being audited to determine that you’ve properly documented and filed for it. If they determine you didn’t adequately meet the published coverage guidance, they’ll tell you formally in writing of your options. After you exercise, or don’t exercise, your options, they send their findings to your local MAC, who then issues a recoupment notice. It’s possible that they could determine you’re owed monies (but that’s less common). Once the MAC issues you the notice, you have claims appeal rights beginning at a level 1 appeal (Redetermination). So, all is not lost and you can make your case to another entity.

Q: Do you have any “nuggets” you can offer to help us improve our charting with audits in mind?

Yes. As you can see, strict adherence to payer coverage guidance is crucial. Continue to adjust your documentation whenever payer guidance changes. That means having someone from your office regularly check for coverage-policy updates and then spread the word (change or not, so there’s backup). Even without a guidance change, someone on your staff should be monitoring your charts. Lastly, consider periodically using an outside reviewer, as this is a normal part of compliance anyway.

If you get one of these requests, don’t panic. Assemble all your documentation and carefully follow the instructions for submission—but keep an eye on the process

Mr. Larson is a senior consultant at the Corcoran Consulting Group and is based in Tucson, Arizona. He can be reached at plarson@corcoranccg.com.