Ophthalmology coverage hinges on knowing the payer | AAO 2026

The same cataract surgery, glaucoma procedure or imaging test can be covered by one payer and denied by another, making payer identification the first step in ophthalmic coding, according to a session presented at the American Academy of Ophthalmology (AAO) annual meeting being held Oct. 9 through Oct. 12, 2026, in New Orleans.

The course, ‘Decoding Payer Policies: What Every Practice Needs to Know,’ was led by Academy coding and health policy staff, a glaucoma specialist and a retina specialist. They compared Medicare coverage policies with Medicare Advantage and commercial plan rules. Identifying the payer is the first question in any coding decision, said Joy Woodke, COE, OCS, OCSR, Director of Ophthalmic Practice at AAO, because each payer sets its own frequency limits and documentation requirements.

National coverage determinations are published by CMS and bind every Medicare Administrative Contractor (MAC). Local coverage determinations (LCDs) come from individual MACs and fill gaps in national policy, while local coverage articles (LCAs) list the CPT codes and the ICD-10 codes payable with them. These policies can change at any point in the year, not only with the October ICD-10 update, presenters said.

Variation among Medicare Advantage plans is permitted by law, said Brandy Keys Sokolow, M.P.H., the director of health policy at AAO. When asked whether plans may institute prioritization or step therapy, “the answer is quite simply yes,” she said, because Medicare Part C gives plans flexibility to administer benefits in ways that save the program money.

“The way that the law was written for Medicare Part C or Medicare Advantage or Medicare Disadvantage, as we like to call it in our office, is it provides them that flexibility to administer the benefits in a way that can save the program money,” Keys Sokolow said, earning a collective audience chuckle from the audience. “So, unfortunately, it leads to a lot of variation across policies, and I know that that's something that we all struggle with day to day.”

Cataract and glaucoma rules diverge

Cataract surgery complexity is defined by technique and supporting diagnoses rather than difficulty alone, said Amy Zhang, M.D., clinical assistant professor of ophthalmology at the University of Michigan. Billing complex code 66982 instead of routine code 66984 requires the operative note to document both why and how, such as a pupil that would not dilate and required a mechanical iris expansion device. Mature cataract requiring dye to visualize the capsule qualifies only under some payer policies. Commercial plans add their own thresholds. Blue Cross Blue Shield of Michigan, for example, requires best corrected visual acuity of 20/40 or worse or a documented two-line loss under glare.

Medicare's revised minimally invasive glaucoma surgery (MIGS) LCD, issued by Noridian and adopted by Palmetto, NGS, CGS and WPS, requires documented trial and failure of medication and laser therapy before MIGS, even when combined with cataract surgery. Combining device types is not covered. Noridian also removed 46 diagnosis codes, including low-tension and pigmentary glaucoma, and ocular hypertension is not a covered diagnosis.

Imaging limits and same-day denials

Audit scrutiny is rising. Zhang cited a 51% error rate in a review of cataract surgery claims and a 36% error rate in a broader review that included MIGS, with 18% of practices failing to respond to additional documentation requests.

Payers are also denying office visits billed the same day as ophthalmic testing, a policy spreading from national to regional plans, including Anthem, Keys Sokolow said. Payers cite Chapter 1 of the National Correct Coding Initiative manual but overlook its section stating that special ophthalmological services are separately reportable, she said. In February 2025, Humana removed ophthalmologists from its downcoding policy after Academy pushback.

Practices that find their own billing errors should issue voluntary refunds, Woodke said. “It's much easier to send a voluntary refund and then submit the corrected claim, especially within timely filing, than to have the auditors find that.”