Using an Assistant at Cataract Procedures


How to Request an Authorization:

Medicare requires a medical necessity review prior to using assistant-at-cataract-related procedures. If you anticipate needing an assistant at a cataract-related procedure to be performed on a Medicare beneficiary, please:

1. First notify HSG by calling 1-866-800-8750.
2. Complete the authorization request form and gather the necessary documentation.
3. Submit the paperwork to our Tampa office by fax or mail.

For Scheduled Procedures:.

At least one week prior to the scheduled procedure, please submit:

• Documentation of the complicating medical condition requiring an assistant during the cataract procedure
• History and physical
• The completed authorization request form.

For Emergency Procedures:

Within 48 hours of the procedure, please submit:

• Documentation of the complicating medical condition requiring the assistant during the cataract procedure.
• History and physical.
• The completed authorization request form.
• Documentation of the emergency situation that required immediate surgery.

Background Information:

Per Section 1862 (a)(15) of the Social Security Act, Medicare will not pay for the use of an assistant at cataract-related procedures unless its local Quality Improvement Organization (QIO) has approved the use of an assistant due to complicating medical factors. Note: This requirement does not apply to Medicare Advantage Plan cases.

Failure to obtain pre-approval or providing inaccurate information may result in sanctions being applied that can include civil monetary penalties and assessments per instance of improper or unnecessary services or exclusions from participation in Medicare.

Under our QIO contract with Medicare, HSAG is responsible for reviewing California health care providers' requests to bill Medicare for using an assistant during any of the following procedures:

• CPT Code 66852: Removal of lens material; pars plana approach, with or without vitrectomy
• CPT Code 66920: Removal of lens material; intracapsular
• CPT Code 66930: Removal of lens material; intracapsular, for dislocated lens
• CPT Code 66940: Removal of lens material; extracapsular
• CPT Code 66986: Exchange of intraocular lens

This requirement is in effect for all of the above cataract surgeries being performed on Medicare beneficiaries.