For Dates of Service Before January 1, 2020

Cataract Surgery

When a surgeon performs all of the components of cataract surgery, including preoperative, surgical, and postoperative care, the appropriate surgical procedure code should be indicated on the claim. Providers should follow the guidelines outlined here if another physician or an optometrist performs postoperative care.

Surgical Care Only

Submitting claims for surgical care only is allowed when one surgeon performs the cataract surgery and another provider delivers postoperative management. Surgical care only is identified by adding modifier 54 (Surgical care only) to the appropriate procedure code on the claim. Use of modifier 54 is allowed only for cataract surgery procedure codes 66820-66821, 66830-66984 for preoperative care and surgery when post-operative care is performed by an optometrist. Wisconsin Medicaid does not separately reimburse surgical care (modifier 54) for any other surgical procedure codes.

The following criteria apply when using modifier 54:

• The modifier is allowable only for the surgeon who performed the surgery.
• The surgeon is reimbursed at 80 percent of the global maximum allowable fee for performing the surgery.
• Wisconsin Medicaid will not reimburse more than what the global period allows for a given surgery. The sum of reimbursement for separately performed "surgical care only" and "postoperative management only" will not exceed the global maximum allowable fee for cataract surgery, regardless of the number of providers involved. Reimbursement may be reconciled in post-pay audit.
• Hospital inpatients: If cataract surgery is performed on a hospital inpatient, only the surgeon may submit claims for the appropriate cataract procedure codes with modifier 54. Any other provider who sees the member during the inpatient stay will be reimbursed only for medically necessary E&M procedures (e.g., 99232 [subsequent hospital care]).

Postoperative Management

Postoperative management for cataract surgery is allowed only when a physician or other qualified provider performs the postoperative management during the postoperative period after a different physician has performed the surgical procedure.

Modifier 55 (Postoperative management only) should be used with the appropriate cataract surgery procedure code when another provider delivers all or part of the postoperative management or when the surgeon provides a portion of the postoperative management. Use of modifier 55 is allowed only for cataract surgery procedure codes 66820-66821, 66830-66984 for postoperative care when performed by an optometrist. Wisconsin Medicaid does not separately reimburse postoperative management (modifier 55) for any other surgical procedure codes.

The following criteria apply when using modifier 55:

• Modifier 55 includes all postoperative visits performed by a provider. Quantity is limited to "1" per provider during the entire postoperative period.
• Wisconsin Medicaid will not reimburse more than the global maximum allowable fee for a given surgery, including postoperative management. The sum of reimbursement for separately performed "postoperative management only" and "surgical care only" will not exceed the global fee for cataract surgery, regardless of the number of providers involved. Reimbursement may be reconciled in post-pay audit.
• The provider is reimbursed at 20 percent of the global maximum allowable fee for providing postoperative management for major surgery.
• When two or more provider types (i.e., ophthalmologists, optometrists, or other qualified providers) split postoperative management, reimbursement will be reduced proportionately following post-pay review of the claims and/or medical records.
• The surgeon and all postoperative management providers are required to keep a copy of the written transfer agreement with the dates of relinquishment and assumption of care in their member's medical record.
• The dates that the postoperative management was provided as indicated on the claim must occur on and after those indicated on the transfer agreement. A claim with a DOS prior to what was indicated on the transfer agreement will be denied during post-pay review and the reimbursement will be recouped.
• Wisconsin Medicaid does not require providers to submit additional supporting clinical documentation as part of the claims submission process for cataract surgery.

Preoperative Management

Preoperative management is included in the reimbursement rate for surgical care and is not separately reimbursable. Wisconsin Medicaid does not separately reimburse modifier 56 (Preoperative management only) when submitting claims for preoperative management.