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QIO TRANSMITTAL SERIES ISSUE: Review of the Use of An Assistant at Cataract
Surgery - Printable
pages Section 4107 of the Omnibus Budget Reconciliation
Act of 1990 stated that Medicare will not pay (for any reason) for assistants
at cataract surgery except in cases of certain specific cataract
procedures. Since Section 1186(a)(15)
of the Social Security Act prohibits Medicare payment for the services of an
assistant at any cataract surgery, unless, prior to the surgery, the QIO has
approved the use of an assistant based on the existence of a complicating
medical condition, preprocedure review is required for the use of an
assistant at the specified cataract surgical procedures being performed on
Medicare beneficiaries. The purpose
of the review is to determine the medical necessity of the use of the
assistant during cataract surgery. QIO
review for the medical necessity of the assistant's services is required for
cataract surgeries with the following CPT codes: 66852, 66920, 66930, 66940, and 66986. This
requirement is in effect for all of the above cataract surgeries being
performed on Medicare beneficiaries regardless of the setting (inpatient
hospital, outpatient hospital, ambulatory surgical center or physician
office). Process for Obtaining Review of the Use of An Assistant at Cataract
Surgical Procedures All
reviews of the use of an assistant at cataract surgical procedures are
conducted via telephone. NHCQF's
toll-free number for these reviews is 1-800-772-0151 ext 165; review may be
obtained between the hours of 8:30 a.m. and 4:30 p.m. Monday through Friday
(excluding holidays). When
NHCQF is called for the use of an assistant at cataract surgery review a
NHCQF Review Nurse will obtain medical information about the need for the
assistant. If the surgical necessity
criteria are not met, the case will be referred to a QIO Physician Consultant
for review and if necessary, for discussion with the attending physician. If
the QIO Physician Consultant determines (with or without discussion with the
attending physician) that the use of an assistant at cataract surgery is
medically indicated, the person who made the referral will be so advised (by
telephone). If the QIO Physician Consultant determines, after
discussion or attempted discussion with the attending physician, that the use
of an assistant at cataract surgery is not medically indicated, the person
making the referral will be so notified, by telephone and in writing. Further appeal rights will be outlined in
the denial notification. The review is usually performed either before the
initial cataract extraction or before the insertion of a lens when it is
being inserted at a time different from the initial extraction (i.e., during
a different operative episode). If
preprocedure approval for the use of an assistant at cataract surgery is not
obtained from the QIO, the services may not be billed to Medicare; however
the regulations do provide for post-surgery review in instances where an
assistant at surgery was used without prior approval because an emergency
arose during the surgical procedure. Since the QIO reviewers
are available for telephone review during normal operating hours, it is expected
that scheduling would not be adversely affected (in most instances) by the
requirement for referral for review prior to the use of an assistant at the
procedure. Medicare beneficiaries
cannot be charged for the use of an assistant if NHCQF disapproves the use of
the assistant or if approval for the use of the assistant is not
requested. Beneficiaries cannot be
requested to accept liability or to waive Medicare payment, i.e., there is no
situation where a Medicare beneficiary can be charged to pay for the use of
an assisting physician during his/her cataract surgery.
June
2006 Next
Chapter: Quality Improvement
Program |
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Copyright © 2005 Northeast Health Care Quality Foundation, all rights
reserved |
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