Using an Assistant at Cataract Procedures

Medicare requires a medical necessity review prior to using an assistant at cataract-related procedures. (See the background details about this requirement.)

If you anticipate needing an assistant at a cataract-related procedure to be performed on a Medicare beneficiary, please:

1. First, notify Qualis Health by calling (877) 290-4346
2. Complete the authorization request form and gather the necessary documentation (described below)
3. Submit the paperwork to our Seattle office by fax or mail.

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

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, which can include civil monetary penalties and assessments per instance of improper or unnecessary services, or exclusion from participation in Medicare.

Under our QIO contract with Medicare, Qualis Health is responsible for reviewing Idaho and Washington healthcare providers' requests to bill Medicare for using an assistant at 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 regardless of the setting (inpatient hospital, outpatient hospital, ambulatory surgical center, or physician office).