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LCD ID Number: L35091 Status: A-Approved
LCD Title: Cataract Extraction (including Complex Cataract Surgery)
Geographic Jurisdiction: Colorado Other Jurisdictions
Original Determination Effective Date:
10/01/2015
Original Determination Ending Date:
Revision Effective Date:
07/11/2021
Revision End Date:
CMS National Coverage Policy:
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for cataract extraction services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for cataract extraction services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
IOM Citations:
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
- Chapter 15, Section 30.4 Optometrist's Services and Section 120 Prosthetic Devices
- Chapter 16, Section 10 General Exclusions from Coverage and Section 90 Routine Services and Appliances
- CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
- Chapter 1, Part 1, Section 10.1 Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery, Section 80.8 Endothelial Cell Photography, Section 80.10 Phaco-Emulsification Procedure - Cataract Extraction, and Section 80.12 Intraocular Lenses (IOLs)
- CMS IOM Publication 100-04, Medicare Claims Processing Manual,
- Chapter 14, Section 40.3 Payment for Intraocular Lens (IOL)
- Chapter 32, Section 120 Presbyopia-Correcting (P-C IOLS) and Astigmatism-Correcting Intraocular Lenses (A-C IOLs) (General Policy Information)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual,
- Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD
Social Security Act (Title XVIII) Standard References:
- Title XVIII of the Social Security Act, Section 1832(a)(2)(F) defines ASC Surgical Services furnished in connection with surgical procedures.
- Title XVIII of the Social Security Act, Section 1833(t)(1)(B)(iii) states Implantable Items may be covered as defined in SSA Section 1861(s) in Hospital Outpatient Departments.
- Title XVIII of the Social Security Act, Section 1861(s)(1) describes Physicians’ Services.
- Title XVIII of the Social Security Act, Section 1861(s)(2)(A) describes Incident To Physician’s Professional Service.
- Title XVIII of the Social Security Act, Section 1861(s)(2)(B) describes Incident To Physician’s Professional Service furnished to Hospital Outpatients.
- Title XVIII of the Social Security Act, Section 1861(s)(8) refers to Eyeglasses or Contact Lenses Furnished after Cataract Surgery With Insertion of IOL.
- Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
- Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
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