Palmetto Responds to Cataract Surgery LCD Comments (2025)

Palmetto GBA recently amended its Cataract Surgery Local Coverage Determinations (LCDs) to reflect a focus on the adult patient and a more complete description of functional status.
In response to comments the J1 Part A/B Medicare administrative contractor (MAC) received, the title of the final policy was amended to appropriately reflect the adult patient population. Palmetto GBA alsoremoved the specific Snellen visual acuity threshold from the final LCD. The reporting requirement of the “best corrected” Snellen visual acuity remains, however. As does the expectation that the medical records supporting the cataract extraction identify the activity limitations (e.g., in self-care and mobility) and participation restrictions (e.g., in interpersonal interactions and relationships and community, social and civic life) are also reported.
These terms may be new to physicians, hospitals, and ambulatory surgical centers (ASCs) providing cataract surgery but are reflective of long-standing concepts included in such well-established instruments like the National Eye Institute’s Visual Functioning Questionnaire – 25 (VFQ – 25).
Toprovide guidance to physicians, hospitals, and ASCs on how best to communicate functional status for patients requiring cataract extraction, Palmetto GBA has incorporated the concepts of the International Classification of Functioning, Disability and Health (ICF) taxonomy into the final version of the LCD.
Below is a case scenario demonstrating the value of going beyond diagnosis by using the concepts of the ICF. Please note that while Palmetto GBA is encouraging physicians and hospitals providing cataract surgery to consider the conceptual framework of the ICF, Medicare does not require the reporting of the ICF codes.
Going Beyond Diagnosis® Case Scenario – The case scenario below is meant to stimulate thinking about cognitive processes that take place during a patient encounter, but currently may not be captured in the clinical documentation. Palmetto GBA advocates the use of the Going Beyond Diagnosis® Form for Cataract Surgery in Adults, to ensure the documentation supporting cataract surgery includes not only a measure of visual impairment (e.g., best corrected Snellen visual acuity) but also functional status information documenting the effect of the visual impairment on the individual’s overall health status (that’s where the domains/categories listed under ‘activities and participation’ in the case scenario come into play):
Case Narrative: Ms. Smith, a 70-year-old woman living independently in her own home, presented to her primary care physician complaining of cloudy vision. She reported that colors seemed faded and increasingly has noted glare associated with headlights from other cars at night. She has curtailed her driving and has been staying at home more and more. She reports difficulty reading street signs and newspapers despite using her bifocals – the latter prompting her to seek medical attention. Her primary care physician performed a non-dilated exam and identified that she has bilateral cataracts. Ms. Smith is given a referral to see an ophthalmologist for further evaluation and possible cataract extraction.
Going Beyond Diagnosis® Description of Case Narrative – In this case, impairments of body structure and function contribute to the observed activity limitations and performance restrictions. If these are captured and systematically reported in the clinical record, Palmetto GBA would be in a better position to approve the services provided. If, however, ‘blurred vision’ is the only rationale documented for recommending and performing a cataract extraction it leaves room for questioning whether the beneficiary truly needed the service.
Below are examples of relevant ICF categories available for organizing, documenting, and communicating information regarding the visual impairment, activity limitations, and participation restrictions that may accompany a clinically significant cataract. While Palmetto GBA is not requiring use of the ICF coding system itself, use of the online Going Beyond Diagnosis® Form for Cataract Surgery in Adults will help capture the patient-centered data needed to improve the communication between providers and Palmetto GBA. If you wish to see the full descriptions associated with the identified ICF codes, you may access them online via the World Health Organization’s (WHO) ICF Browser and searching terms like “eye,” “reading,” “walking,” and “climbing.”
ICD-9-CM

• 366.10 – Cataract, unspecified

ICF
Body Structure – The eye

• s2204 – Lens of eye

Body Function – Sensory functions – seeing and related functions

• b210 – Seeing functions
  • b2100 – Visual acuity functions
  • b21000 – Binocular acuity of distant vision
  • b21001 – Monocular acuity of distant vision
  • b21002 – Binocular acuity of near vision
  • b21003 – Monocular acuity of near vision
• b2102 – Quality of vision
  • b21020 – Light sensitivity
  • b21023 – Visual picture quality

Activities and Participation

• d166 – Reading – Performing activities involved in the comprehension and interpretation of written language (e.g., books, instructions, or newspapers in text or Braille) for purposes of obtaining general knowledge or specific information.
• d450 – Walking
  • d4503 – Walking around obstacles
• d455 – Moving around
  • d4551 – Climbing (e.g., steps or curbs)
• d4751 – Driving
• d9202 – Arts and culture – (includes reading for pleasure)
• d9205 – Socializing

The effective date of the J1 LCDs for Cataract Surgery in Adults is Aug. 26.
Source: Palmetto GBA Aug. 19 online article.