Cataract Claims Double Dipped? These RACs Are Checking

correct coding for cataract removal

If you perform cataract removal services in RAC regions 1, 2, or 3, be on alert. Coding and unit errors are under the spotlight. Here’s the scoop.

What & Where: Learn the RACs and Regions Involved

RACs Cotiviti Healthcare and Performant have both posted the following as approved audit issues:

  • 0083 – Cataract Removal Excessive Units – Partial Denial
  • 0084 – Cataract Removal Excessive Units – Full Denial.

Cotiviti lists these issues for region 2 extending from Texas up to Minnesota (J5, J6, JH) and region 3 in the southeast (JJ, JM, JN), while Performant is doing the review for region 1, mostly in the midwest and northeast (J8, J15, JK).

These are automated reviews, meaning the RACs use data-mining rather than requesting and reviewing medical records.

Why: Understand Correct Coding for These Cataract Claims

Here are the descriptions for issue 0083 (Partial Denial):

  • Cotiviti:Cataract removal cannot be performed more than once on the same eye on the same date of service. This query identifies overpayments where providers are billing for more than one unit of cataract removal for the same eye, on the same line of the claim.”
  • Performant: The description is the same as Cotiviti’s, but adds this: “Affected codes: 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984.”

For 0084 (Full Denial), these are the descriptions:

  • Cotiviti: “CPT® Codes describing cataract extraction are mutually exclusive of one another. Only one code from the affected CPT® code range may be reported per date of service and for each eye.”
  • Performant: Again, the description is the same as Cotiviti’s, but with an addition, listing the same affected codes as issue 0083.

Rationale: Both RACs list National Correct Coding Initiative (NCCI) Policy Manual (Chapter 8, Section D) as a resource. If you check subsection D.3, you’ll see almost the exact wording of description 0084. Once you know the NCCI rule, issue 0084 makes sense. And issue 0083, about reporting only one unit of cataract removal per eye per claim line, makes sense anatomically. (MUEs should have caught most of those errors anyway.)

Who: See the Claims Types Being Scrutinized

For Cotiviti, these issues are listed for these claim types:

  • Physician/Non-Physician Practitioner
  • Outpatient
  • ASC.

Performant lists those same claim types for 0084, but switches things a bit for 0083:

  • Professional Services
  • Outpatient
  • ASC.

When: Don’t Be Surprised by 3-Year Review

Cotiviti denotes the issues as approved on March 14, 2018, and lists the date of service for issue 0083 as three years prior to the informational letter date.

The information is similar for Performant, with March 19, 2018, as the date approved date and a policy to exclude “claims having a ‘claim paid date’ that is more than 3 years prior to the Informational letter date.”

How About You?

Are you in one of the areas affected? What’s your experience with RAC reviews?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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