Cataracts

stmsmith

Hello all, do you any of you have issues with cataracts? Documentation, completeness, Medical Necessity? How are you dealing with them? Do you have an audit form that you utilize? I just came into this position last week and this is one of the topics I that was brought up in discussions with me.  It seems we have written off over $2million this year. Any assistance would be appreciated.

ronaldhirsch

You should never have a cataract denial. Cataract extraction is (almost) never urgent. You have plenty of time to get notes. No surgery gets scheduled unless you have office notes showing indications for the surgery. Unless you have a rogue surgeon, the documentation should be in the office notes and you jst need to scan it into the hospital chart. The basics are: Cataract causing symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function not correctable with a tolerable change in glasses or contact lenses resulting in specific activity limitations and/or participation restrictions including, but not limited to reading, viewing television, driving, or meeting vocational or recreational needs. Surgery is not deemed to be medically necessary purely on the basis of lens opacity in the absence of symptoms. Also other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the primary cause of decreased visual function.

stmsmith

Ron I totally agree, we should never have denials.  What I have found out in reviewing some of them is they are denying for Medical Necessity. The providers are just not documenting. I think I have just opened a can of worms here.