This article was previously published in the April 19, 2018, issue of the MLN Connects®![]()
April 24, 2018
Ophthalmology Services: Questionable Billing and Improper Payments
The Office of the Inspector General (OIG) reports that Medicare is vulnerable to fraud, waste, and abuse for wet Age-related Macular Degeneration (wet AMD) and cataracts:
- Administration of Lucentis injections for wet AMD more than once every 28 days (based on local coverage determinations)
- Billing for a second cataract surgery on the same eye
- Submitting disproportionately more claims for complex than standard cataract surgery
Review the following resources for proper claims coding, billing, and payment:
- Questionable Billing for Medicare Ophthalmology Services
OIG Report, September 2015 - Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims
OIG Report, December 2014 - Cataract Removal, Part B
MLN Matters® Special Edition Article - Implementation of CMS Ruling Regarding Presbyopia-Correcting Intraocular Lenses for Medicare Beneficiaries
MLN Matters Article - Multiple Procedure Payment Reduction on the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures
MLN Matters Article - Medicare Vision Services
Fact Sheet - NCCI Policy Manual for Medicare Services, Chapter 8 Section D: Ophthalmology

- Medicare National Coverage Determinations Manual, Part 1 - Section 10.1: Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery

- Medicare Benefit Policy Manual, Chapter 15, Section 120: Prosthetic Devices and Section 260.2: Ambulatory Surgical Center Services


