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Too many YAGs within the postop period
Excessive YAG capsulotomies soon after cataract surgery invite scrutiny of the practice.
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Dr. A is an extremely busy cataract surgeon who performs several thousand cataract surgeries per year. He also performs a large number of YAG laser capsulotomies. During a quality assurance review of these surgeries for the ambulatory surgery center (ASC), the reviewers noted that almost all of the YAGs were performed within 90 days of the initial cataract surgery. Of those cases going to laser, some had mild visual complaints, but few had complaints of lifestyle changes due to their vision.
There are several concerns. In the Medicare population, most surgeons perform two to four YAG capsulotomies for every 10 cataract surgeries with IOL. YAG capsulotomies are usually performed within 36 months of the initial cataract surgery, and are rarely required within the first 90 days postop. For a large volume of cataract surgeries, it is reasonable to expect a large number of YAG capsulotomies, but not so close to the primary cataract operation.
This elevated utilization makes the practice a target for scrutiny. On review, a Medicare auditor will apply the Local Medical Review Policies (LMRPs) to determine the validity of a claim and the medical necessity for the procedure. LMRPs generally state that YAG capsulotomies within the 90-day postop period should be rare. When a YAG is performed within the global period, the payer requires additional chart documentation to support the medical necessity.
Moreover, these same carrier policies require documentation of how vision is adversely affecting Activities of Daily Living, regardless of when the procedure is performed. In other words, no matter what the best corrected vision may be, a complaint from the patient must include difficulty performing his or her daily routine. Many of the policies accept a glare test, with a resulting drop in vision, if “glare” is part of the patient complaint.
Clinical findings of posterior capsule opacity do not, in themselves, justify surgery. The patient’s disability and complaints are a vital part of the justification for a YAG capsulotomy. Before proceeding with YAG capsulotomy, the patient should be questioned about the degree of difficulty he or she is experiencing. Special attention is merited for those patients who have visual complaints within the postop period.