Checklist: Cataract extraction
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for surgical services: cataract extraction. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
| Documentation is for the correct beneficiary. |
|
| Documentation contains a valid and legible signature. |
|
| Documentation includes procedure notes or operative report of the cataract extraction performed for the date of service under review. |
|
| Documentation includes evidence that the patient has a cataract. |
|
| Documentation includes evidence that the patient has impairment of visual function due to the cataract(s) impacting ability to carry out activities of daily living. |
|
| Documentation includes evidence that the patient has been educated about the risks and benefits of the cataract surgery and alternative options and provided informed consent. |
|
| Documentation of any other pre-operative ophthalmologic studies/work-up completed. |
|
| Evidence of education provided to the patient to contact ophthalmologist if they have a change in visual symptoms during the interval between the examination and surgery. |
|
| If applicable and required, submitted documentation should include a beneficiary waiver of liability. |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.