TL;DR: The Centers for Medicare & Medicaid Services modified NCD 60, its coverage policy for preoperative visual tests and general anesthesia in cataract surgery, effective January 9, 2026. Here's what changes for billing teams.
CMS cataract surgery coverage policy under NCD 60 has been updated in the NCD 60 Medicare system. The policy governs what preoperative testing and anesthesia CMS will reimburse alongside cataract procedures with intraocular lens (IOL) implants — one of the highest-volume procedures in Medicare. The policy does not list specific CPT or HCPCS codes, but the clinical and billing guidelines within it directly affect what your team can submit without triggering a claim denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery |
| Policy Code | NCD 60 |
| Change Type | Modified |
| Effective Date | January 9, 2026 |
| Impact Level | High |
| Specialties Affected | Ophthalmology, Anesthesiology, Ambulatory Surgery Centers |
| Key Action | Audit preoperative test billing for cataract cases — Medicare covers only one comprehensive eye exam and one A-scan (or B-scan if medically justified) when cataract is the sole diagnosis |
CMS Cataract Surgery Coverage Criteria and Medical Necessity Requirements 2026
The CMS cataract surgery coverage policy under NCD 60 is built around a simple premise: most cataracts don't need a battery of tests before surgery. Medicare's position is that a comprehensive eye examination and a single scan — typically a diagnostic ultrasound A-scan — are sufficient in straightforward cases.
That's the baseline. Everything beyond it requires documented medical necessity.
For simple cataracts, Medicare covers one comprehensive eye examination (or a combination of brief and intermediate exams that together don't exceed the cost of a comprehensive exam) plus one A-scan. If the patient has a dense cataract that limits A-scan utility, a B-scan may be substituted — but only when medically justified, and that justification needs to be in the documentation.
Any additional preoperative tests beyond those two items are denied as not reasonable and necessary unless a secondary diagnosis explains them. If your patient has both a cataract and another ocular condition, document that additional diagnosis clearly. The medical need for every additional test must be fully documented in the record. "Fully documented" here means the A/B Medicare Administrative Contractor's medical staff will be evaluating whether that documentation holds up — not just whether you included a line in the chart.
The real issue with this coverage policy is how frequently cataract billing teams run additional tests as a matter of routine — corneal topography, specular microscopy, optical biometry beyond a standard scan — without tying those to a documented secondary diagnosis. NCD 60 is explicit: if the only diagnosis is cataract, those additional tests don't get covered. That's a straightforward claim denial risk that can be mitigated with better documentation habits.
One nuance worth flagging: because cataract surgery is elective, the patient may choose to delay or switch surgeons. In those cases, it may be medically appropriate for the operating physician to conduct a repeat examination before surgery. The policy allows coverage for that additional exam to the extent the A/B MAC's medical staff considers it reasonable and necessary. This is not a blank check — it's MAC discretion, and your reimbursement depends on that contractor's local interpretation.
This is where knowing your local MAC's standards matters. Prior authorization is not mentioned in this policy, but local coverage determinations and MAC-level guidance will shape what gets paid in your region. If you bill across multiple MAC jurisdictions, don't assume one contractor's tolerance for repeat pre-op exams applies everywhere.
CMS Cataract Surgery Exclusions and Non-Covered Indications
The exclusion in NCD 60 is broad and simple: any preoperative test beyond the covered baseline gets denied when cataract is the only diagnosis.
That means corneal topography, pachymetry, specular microscopy, extended biometry studies, or other diagnostic tests your team may order as standard protocol are all at risk. If there's no secondary diagnosis supporting them, and no documentation of why they're medically necessary for that specific patient, CMS will not reimburse them.
The policy doesn't enumerate a list of excluded tests — it frames the exclusion as anything "other than" the covered baseline. That structure puts the burden on your billing team to justify anything additional, not on Medicare to define a prohibited list. That's a harder position to defend in a post-payment audit.
Billing guidelines here are clear: don't submit additional pre-op tests for cataract-only diagnoses without documented secondary diagnoses and explicit medical necessity language in the record.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Comprehensive eye examination, cataract as sole diagnosis | Covered | Not specified in policy | One exam per surgical workup; brief/intermediate combo acceptable if total charge doesn't exceed comprehensive exam charge |
| Diagnostic ultrasound A-scan (simple cataract) | Covered | Not specified in policy | Standard IOL power determination; one scan covered |
| Diagnostic ultrasound B-scan (dense cataract) | Covered when medically justified | Not specified in policy | Must document why A-scan is insufficient; medical justification required |
| Additional preoperative tests, cataract-only diagnosis | Not Covered | Not specified in policy | Denied as not reasonable and necessary without additional documented diagnosis |
| Additional preoperative tests, additional diagnosis present | Covered when medically justified | Not specified in policy | Additional diagnosis and medical necessity must be fully documented; MAC determines reasonableness |
| Repeat examination by operating surgeon (patient delay/surgeon change) | Covered at MAC discretion | Not specified in policy | Coverage depends on A/B MAC medical staff determination; not guaranteed |
| General anesthesia, medically indicated cataract surgery | Covered when medically justified | Not specified in policy | Must be accepted practice in local community for the specific medical indication |
CMS Cataract Surgery Billing Guidelines and Action Items 2026
The effective date of January 9, 2026 means this policy is already live. If your team hasn't reviewed your cataract pre-op billing workflows against NCD 60, do it now.
| # | Action Item |
|---|---|
| 1 | Audit your preoperative test patterns for cataract cases. Pull a sample of cataract surgery claims from the past 90 days. For any case where the only diagnosis is cataract, check whether your team billed anything beyond a comprehensive eye exam and one A-scan or B-scan. Flag those claims for documentation review before your next audit cycle. |
| 2 | Establish a documentation standard for secondary diagnoses. If you routinely order additional preoperative tests — corneal topography, specular microscopy, extended biometry — your providers must link each test to a documented secondary diagnosis. Create a checklist or template that forces this link before the test is ordered, not after the claim is submitted. |
| 3 | Train your providers on the B-scan justification threshold. A B-scan is covered only when the A-scan is insufficient because of a dense cataract. That clinical rationale needs to be in the chart, explicitly. "Dense cataract limiting A-scan accuracy" should appear in the record, not just "B-scan ordered." |
| 4 | Build a protocol for repeat pre-op exams when patients switch surgeons or delay surgery. The policy allows the operating surgeon to perform a repeat examination — but only when the A/B MAC considers it reasonable and necessary. Document the reason for the repeat clearly: "Patient previously evaluated by referring physician; surgery delayed [X months]; operating surgeon conducting independent pre-surgical evaluation." Don't just bill a second comprehensive exam and assume it'll pass. |
| 5 | Review your general anesthesia documentation for cataract cases. General anesthesia in cataract surgery is covered when specific medical indications make it the accepted local standard. That acceptance needs to be supported by documentation — not just an anesthesia request. Work with your anesthesiology team and medical director to define what qualifies and make sure the chart reflects the clinical rationale before the claim goes out. |
| 6 | Check your MAC's local coverage determinations. NCD 60 is a national policy, but your A/B MAC has discretion on edge cases — repeat exams, borderline B-scan justifications, and additional tests tied to secondary diagnoses. Look up your MAC's LCDs and any applicable billing guidelines for cataract surgery before your next pre-auth or pre-billing review. If you're not sure how your MAC interprets the policy, talk to your compliance officer or billing consultant before the effective date rules lead to denials. |
| 7 | Flag prior authorization requirements at the payer level, not just Medicare. NCD 60 doesn't mention prior authorization for these tests, but your commercial payers may have their own requirements layered on top. Your cataract surgery billing team should maintain a payer-by-payer matrix that covers both Medicare rules and commercial prior auth thresholds. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Cataract Surgery Pre-Op Testing Under NCD 60
The policy data for NCD 60 does not list specific CPT, HCPCS, or ICD-10 codes. This is a known limitation of this NCD — it sets coverage principles without enumerating the codes those principles apply to.
That makes cataract surgery billing more complex, not less. Your billing team needs to cross-reference NCD 60's criteria against the specific codes you submit for preoperative testing and anesthesia.
What to Do Without a Code List
Check your MAC's local coverage determinations and billing guidelines for cataract surgery. Most A/B MACs have published LCDs or articles that map NCD 60 criteria to specific codes — covering procedures like ocular ultrasound, biometry, and corneal diagnostics. Those MAC-level documents will tell you exactly which codes are covered, which require medical necessity documentation, and which are categorically excluded for cataract-only diagnoses.
If your MAC hasn't published a supplemental article, contact them directly. The absence of a code list in the NCD doesn't protect you from claim denial — it shifts the burden to your team to know which codes fall within the policy's scope.
Key Clinical Terms to Map to Your Charge Capture
Even without an official code list, the policy references specific test types your team should be able to map:
- Comprehensive eye examination — your charge capture should flag the appropriate E/M or ophthalmology visit code
- Diagnostic ultrasound A-scan — used for IOL power determination in simple cataracts
- Diagnostic ultrasound B-scan — used when dense cataracts limit A-scan utility
- General anesthesia — covered when medically indicated and locally accepted practice
Work with your billing team and medical director to confirm which codes you currently use for each category, then apply NCD 60's coverage criteria to those codes directly.
Get the Full Picture
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.