Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery — NCD 60 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 60, the national coverage determination governing pre-surgery visual tests and anesthesia for cataract surgery, with an effective date of January 9, 2026. Here's what billing teams need to do.

This CMS cataract surgery coverage policy sets firm limits on what Medicare pays before the knife ever touches the eye. The policy restricts covered pre-op testing to one comprehensive eye exam and a single A-scan or B-scan — and denies everything else unless you have a documented additional diagnosis to justify it. This affects ophthalmology practices and ASCs billing Medicare for high-volume cataract procedures across the country.

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Quick-Reference Table

Field	Detail Copy
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	2026-01-09
Impact Level	High
Specialties Affected	Ophthalmology, Anesthesiology, Ambulatory Surgery Centers
Key Action	Audit pre-op test billing for cataract cases and confirm all additional tests have a separate documented diagnosis before submitting claims

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CMS Cataract Surgery Coverage Criteria and Medical Necessity Requirements 2026

NCD 60 in the CMS Medicare system is one of the cleaner national coverage determinations. The coverage policy is narrow by design. For cataract-only patients, Medicare covers two things before surgery: one comprehensive eye examination (or a brief/intermediate exam combination that doesn't exceed the cost of a comprehensive exam), and one biometry scan to determine the correct intraocular lens (IOL) power.

For most simple cataracts, that scan is a diagnostic ultrasound A-scan. If the patient has a dense cataract that makes the A-scan inadequate, a B-scan may be substituted — but you need to show medical justification for that switch. Dense cataract is the documented clinical reason that supports the B-scan over the A-scan. Don't assume the upgrade is automatic.

Everything else is denied. The policy is explicit: where the only diagnosis is cataract, Medicare will not routinely cover additional tests. Claims for those tests get denied as not reasonable and necessary. This is a hard stop — not a soft guidance.

The medical necessity bar for additional testing is equally firm. You must have an additional diagnosis beyond the cataract itself. And that medical need must be "fully documented" — not mentioned in a note, not implied, but fully documented. If your documentation doesn't make the case for why that extra test was needed given a secondary condition, you are looking at a claim denial. Train your clinical documentation team to treat this as a binary: either the record clearly supports the additional test with a separate diagnosis, or the test shouldn't be on the claim.

When the Operating Physician Is Different from the Diagnosing Physician

This is the part of NCD 60 that billing teams overlook most often. Cataract surgery is elective. Patients sometimes delay, shop around, or switch surgeons between the initial diagnosis and the operating room. In those situations, the operating physician may need to repeat the pre-op evaluation.

CMS addresses this directly. If the operating physician is different from the diagnosing physician — or if significant time has passed — it may be medically appropriate to conduct another examination. Coverage in that scenario is determined by your A/B Medicare Administrative Contractor's medical staff. The MAC decides whether those repeated tests are reasonable and necessary given the specific circumstances.

This is a local coverage determination in all but name. The national policy sets the floor; your MAC applies judgment above it. If your practice regularly handles patients referred from other physicians for surgery, document the referral context, the time elapsed since the original diagnosis, and the clinical rationale for repeating tests. That documentation is your defense if a MAC reviewer questions the duplicate testing.

General Anesthesia Under NCD 60

The standard for cataract surgery is local or regional anesthesia. General anesthesia is the exception, not the default.

CMS covers general anesthesia for cataract surgery when two conditions are met. First, there must be particular medical indications making general anesthesia necessary for that specific patient. Second, the use of general anesthesia must be the accepted procedure among ophthalmologists in the local community. Both conditions need to be present. One isn't enough.

The community standard element is important. This isn't just about what the individual surgeon prefers or what the patient requests. It anchors the coverage question to local medical practice patterns. If your practice bills general anesthesia for cataract cases, your documentation should address both the patient-specific indication and the local community standard — even if a MAC audit feels unlikely.

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CMS Cataract Surgery Exclusions and Non-Covered Indications

NCD 60 doesn't bury its exclusions. The policy flat-out excludes additional pre-operative tests when the only diagnosis is cataract. That's not experimental status — it's just not covered. The distinction matters for how you handle patient financial responsibility and ABNs.

If your practice routinely orders corneal topography, specular microscopy, or other advanced pre-op imaging on cataract patients without a separate supporting diagnosis, those tests are not covered by Medicare under this policy. The patient either pays out of pocket, or you need an Advance Beneficiary Notice (ABN) on file before the service is rendered. Running the test and then billing Medicare without that documentation puts the practice at risk — both for the denial and for potential compliance exposure.

Patient-requested additional testing is a common scenario in elective surgery. A patient may want more information before agreeing to surgery. That's understandable clinically, but it doesn't change the coverage policy. The test may still be appropriate to perform. Just be clear with the patient about their financial liability before you order it.

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Coverage Indications at a Glance

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CMS Cataract Surgery Billing Guidelines and Action Items 2026

This policy has been around, but the January 9, 2026 effective date means practices should treat this as a reset — go back and check your current workflows against what the policy actually requires.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Cataract Surgery Visual Tests and Anesthesia Under NCD 60

NCD 60 does not specify CPT, HCPCS, or ICD-10 codes in the policy document. This is consistent with how some older national coverage determinations are written — the policy establishes coverage criteria without tying them to specific billing codes.

This creates a practical challenge for your billing team. The absence of code-level guidance in the NCD means you need to look at two additional sources to build your charge capture rules correctly.

First, check your A/B MAC's local coverage articles associated with NCD 60. MACs often publish companion billing and coding articles that map the NCD criteria to specific CPT codes. These articles are the authoritative source for which codes your contractor expects to see — and which codes trigger medical review.

Second, use the CMS Claims Processing Instructions cross-referenced in NCD 60. Those instructions contain the operational coding guidance that translates the national policy into actual claim requirements.

If your MAC has not published a companion article for NCD 60, or if you are unsure which codes your practice is billing against this NCD, ask your billing consultant to map your current pre-op charge codes against the coverage criteria in the policy. Cataract pre-op billing is high-volume and audit-prone. You want that mapping documented.

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