This policy addresses coverage guidelines for cataract extraction.

Coverage for cataract extraction with Intraocular Lens (IOL) implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries who have a cataract.

Cataract patients must meet all the following criteria:

• The patient has undergone a standardized formal measure of his visual functional status, the results of which suggest the patient’s visual functional status can be improved commensurate with the risk of surgery by undergoing cataract extraction with IOL implant. Such testing can be performed with standardized measurement tools, such as the Activities of Daily Vision Scale or the VF-14.
  
  
• 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 avocational expectations.
    
    
  • Snellen visual acuity of 20/40 or worse. Not all patients with visual acuity of 20/40 or worse require cataract surgery because:
    
    
    • They are able to satisfactorily carry out their activities of daily living with changes in eyeglasses, lighting or other non-operative means.
      
      
    • The operative risk is not commensurate with the potential benefit to the patient.
      
      
    • Other eye diseases such as macular degeneration or diabetic retinopathy rather than cataract are the limiting factor of visual function.
      
      
    • The patient has posterior segment disease requiring surgical or laser intervention and where the cataract is an impairment to visualization.

Generally, patients with visual acuity of 20/40 or better do not require cataract surgery to improve their ability to carry out activities of daily living. However, glare or other environmental factors may adversely affect some patients’ activities of daily living because a cataract is present and significantly diminishes function, even with Snellen acuity of 20/40 or better.

• The patient has been educated about the risks and benefits of cataract surgery and the alternative to surgery and has provided informed consent.
  
  
• The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and an A-scan ultrasound or partial coherence interferometry. Other ophthalmologic studies should be reserved for special situations, such as:
  
  
  • Glare testing for patients with cataracts who complain of glare, yet measure good Snellen acuity when tested in an office circumstance.
    
    
  • B-scan for patients with dense cataracts that preclude visualization of the posterior segment of the eye including the vitreous and/or retina, but not limited to these.

NOTE:

Routine preoperative screening without substantiated signs or symptoms of disease is not covered. When the only diagnosis is cataract(s), testing other than one comprehensive eye examination (or a combination of brief/intermediate examinations not to exceed the charge of a comprehensive examination) plus an appropriate ultrasound scan is not covered.

The goals of the physical exam of a patient whose chief complaint might 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:

• Patient history (including patient's assessment of functional status).
• Snellen acuity and refraction.
• Measurement of intraocular pressure.
• Assessment of pupillary function.
• Examination of ocular motility.
• External examination.
• Undilated and dilated slit-lamp examination (unless dilation is contraindicated by the anatomy of the eye).
• Dilated examination of the fundus (unless contraindicated by the anatomy of the eye).

The maximum appropriate interval between the preoperative examination and the date of surgery is three months, in case there are significant changes in the patient’s health or vision. Patients should be educated to contact the ophthalmologist if they have a change in visual symptoms during the interval between the examination and surgery.

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.

It would not be expected to see bilateral cataract extractions routinely performed on the same day.

The following are contraindications to surgery for a visually impairing cataract:

• 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.

Or,

• A legal consent cannot be obtained.

There are several indications and limitations for use of code 66982:

• A miotic pupil that will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye and that requires the insertion of four iris retractors through four additional incisions, Beehler expansion device, a sector iridectomy with subsequent suture repair of iris sphincter, or sphincterotomies created with scissors.
  
  
• Pediatric cataract surgery may be more difficult intraoperatively because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove and the need for a primary posterior capsulotomy or capsulorrhexis. Furthermore, there is additional postoperative work associated with pediatric cataract surgery.
  
  
• Extraordinary work that may occur during the postoperative period. This is the case with pediatric situations mentioned above and, very rarely, when there is extreme postoperative inflammation and pain.
  
  
• Mature cataract requiring dye for visualization of capsulorrhexis.
  
  
• Pre-existing zonular weakness requiring use of capsular tension rings or segments or intraocular suturing of the intraocular lens.

Refer to Medicare Claims Processing Manual - Pub. 100-04, Chapter 32, §120, for CMS guidelines on IOL insertion benefit following cataract surgery.

Benefit Summary

In summary, the following services are reasonable and medically necessary for the treatment of a cataract:

• A conventional IOL implanted following cataract surgery.
  
  
• Facility or physician services and supplies required to insert a conventional IOL following cataract surgery.
  
  
• One pair of eyeglasses or contact lenses as a prosthetic device furnished after each cataract surgery with insertion of an IOL.

The primary diagnosis submitted by the physician performing the preoperative ophthalmologic evaluation must be cataract (diagnosis codes listed in the diagnosis code section of this policy.

The diagnoses submitted by the physician performing the evaluation and management component of the preoperative workup, when it is medically necessary, should indicate cataract (diagnosis codes listed in the diagnosis code section of this policy) as the primary or secondary diagnosis.

Codes 92002-92014 may not be billed the same day as evaluation and management codes 99201-99333.

Documentation Requirements

Medical records must document the four elements of the preoperative workup described in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this LCD. If records to support claims for cataract surgery with IOL implant do not substantiate the medical necessity for the procedure based on these elements, claims may be reopened and denied and Medicare may request reimbursement.

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medicare Benefit Policy Manual - Pub. 100-02.

Medicare National Coverage Determinations Manual - Pub. 100-03.

Medicare Claims Processing Manual - Pub. 100-04, Chapter 32, Section 120.

Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. 100-09, Chapter 5.

Social Security Act (Title XVIII) Standard References, Sections:

• 1832(a)(2)(F) ASC Surgical Services.
• 1833(t)(1)(B)(iii) Implantable Items Covered in Hospital Outpatient Departments.
• 1861(s)(1) Physicians’ Services.
• 1861(s)(2)(A) Incident To Physician’s Professional Service.
• 1861(s)(2)(B) Incident To Physician’s Professional Service furnished to Hospital Outpatients.
• 1861(s)(8) Eyeglasses or Contact Lenses Furnished after Cataract Surgery With Insertion of IOL.
• 1862 (a)(1)(A) Medically Reasonable & Necessary.
• 1862 (a)(1)(D) Investigational or Experimental.
• 1862(a)(7) Refractive Eye Examinations.

Covered Diagnosis Codes

For procedure code 66982

Note: Use 364.51, 364.59 & 364.75 if the operative note indicates the use of an endocapsular ring to partially occlude the pupil.

*Note: 364.55 Use this code if the operative note indicates micro iris hooks were inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, or sector iridotomy with suture repair of iris sphincter.

*Note: 364.57, Use this code if the operative note indicates permanent intraocular suture or a capsular support ring was employed to place the intraocular lens in a stable position.

*Note: 364.76, Use this code if the operative note indicates a capsular support ring was employed or an endocapsular support ring was used to partially occlude the pupil.

*Note: 364.9, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.00, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.01, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.02, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.03, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.04, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.09, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.10, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.11, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.13, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.14, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.15, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil;
OR
Use this code when Trypan Blue or isocyanine green is employed to enhance visualization.

*Note: 366.16, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.17, Use this code if the operative note indicates dye was used to stain the anterior capsule.

*Note: 366.18, Use this code with 365.51, phacolytic glaucoma or dye staining of the anterior capsule.

*Note: 366.19, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil;
OR
Use this code when Trypan Blue or isocyanine green is employed to enhance visualization.

*Note: 366.20, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.21, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular suture, or a capsular support ring was employed.

**Note: 366.22, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures, or a capsular support ring was employed.

*Note: 366.23, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.30, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, intraocular lens implant was supported by using permanent intraocular sutures, a capsular support ring was employed, or a primary posterior capsulorrhexis was performed.

*Note: 366.32, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, or sector iridotomy with suture repair of iris sphincter.

*Note: 366.33, Use this code if the operative note indicated micro iris hooks were inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, or sector iridotomy with suture repair of iris sphincter.

*Note: 366.41, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.42, Use this code if the operative note or postoperative records indicate an extraordinary amount of work was involved in the pre- or postoperative care.

*Note: 366.43, Use this code if the operative note or postoperative records indicate an extraordinary amount of work was involved in the pre- or postoperative care.

*Note: 366.44, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.45, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 366.46, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

*Note: 379.32, Use this code if the operative note indicates the intraocular lens was supported by using permanent intraocular sutures or a capsular support ring.

*Note: 379.33, Use this code if the operative note indicates the intraocular lens was supported by using permanent intraocular sutures or a capsular support ring was employed.

*Note: 379.34, Use this code if the operative note indicates the intraocular lens was supported by using permanent intraocular sutures or a capsular support ring was employed.

*Note: 379.40, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.

*Note: 379.41, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.

*Note: 379.42, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.

*Note: 379.43, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.

*Note: 379.45, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.

*Note: 379.46, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.

*Note: 379.49, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, or an artificial prosthetic iris was placed in the eye.

*Note: 743.36, Use this code if the operative note indicates use of intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring was employed.

*Note: 743.37, Use this code if the operative note indicates intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring was employed.

*Note: 743.45, Use this code if the operative note indicates the intraocular lens was supported in the eye by using permanent intraocular sutures, a capsular support ring was employed or an endocapsular ring was used to partially occlude the pupil.

*Note: 743.46, Use this code if the operative note indicates the use of micro iris hooks inserted through four separate corneal incisions, Beehler or similar expansion device, multiple sphincterotomies created with scissors, sector iridotomy with suture repair of iris sphincter, the intraocular lens implant was supported by using permanent intraocular sutures or a capsular support ring, or an endocapsular ring was used to partially occlude the pupil.

For procedure codes 66840, 66850, 66852, 66920, 66940, 66983 and 66984.