Keep an Eye on Cataract Cases with Premium IOLs
Don’t let the ambulatory surgery center setting blur your vision for proper payment.
When a Medicare patient has a premium presbyopia-correcting (PC) intraocular lens (IOL) or an astigmatism-correcting (AC) IOL inserted for cataracts, instead of a regular IOL, ambulatory surgery centers (ASCs) must follow specific Medicare coding and billing guidelines to stay compliant. Many ASCs and ophthalmologists are noncompliant without even knowing it. Be sure you know the guidelines, so your ASC is not at risk.
Report the Right IOL
Medicare does not reimburse ASCs for the extra cost of premium lenses in cataract cases — the usual cost of $150 is included in their reimbursement for regular cataract extraction (CPT® codes 66984, 66982, etc.). Although the ASC won’t be paid the difference for the premium lens, you still need to indicate on the Medicare claim form when a premium lens is used.
Bill these premium lenses using V2788 Presbyopia correcting function of intraocular lens for PC IOLs (ReStor®, ReZoom®, Crystalens®, etc.) or V2787 Astigmatism correcting function of intraocular lens for AC IOLs (Toric®, etc.).
Inform the Patient of Noncoverage
While it’s not mandatory to have the patient sign an Advanced Beneficiary Notice of Noncoverage (ABN) because PC and AC IOLs are never covered by Medicare, it’s a good idea so Medicare patients understand they may incur out-of-pocket costs.
Append modifier GA Waiver of liability statement on file, individual case to the V code to indicate that the patient signed an ABN, acknowledging their responsibility for the additional cost of the premium lens; or append modifier GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit if you’re submitting the claim to obtain a denial.
Compliance Issues to Look for When Billing Premium IOLs
There are four compliance issues to watch for when billing premium IOLs to Medicare:
- When the surgeon wants to purchase the premium lens for the case and bring it into the ASC for use, it’s a compliance issue. Medicare does not allow the ASC to bill for cataract extraction procedures with placement of an IOL with modifier 52 Reduced services or any other billing method to convey to Medicare that the ASC did not supply the IOL and, therefore, should not be reimbursed for the IOL supply. Because there is no provision to allow the ASC to break out the implant portion of the procedure from the cataract surgery, Medicare requires the ASC to supply the IOL for all Medicare cataract cases. Medicare considers it to be a false claim when the ASC submits a cataract extraction claim for which they are receiving payment for the IOL when the ASC is not supplying the IOL for the case.
- Medicare does not allow the ASC to reimburse the physician for the IOL, even if the IOL in a cataract case was supplied by the physician. The IOL must be purchased and supplied by the ASC for all Medicare patient cataract cases using regular or premium lenses.
- Ophthalmologists cannot charge and collect money from a Medicare patient for the premium lens implant used in the cataract surgery performed at an ASC. Medicare considers it fraud when the ASC (correctly) purchases the premium lens for a cataract case, and the surgeon bills the Medicare patient the additional cost of the premium lens. The ASC must collect the money related to the IOL directly from the patient. The only extra charge that ophthalmologists can charge Medicare patients in a premium lens case, separate from the surgeon’s normal surgical fee for performing cataract surgery, is for their professional service for the adjustment of the premium lens. The physician cannot be involved in the lens transaction with the patient.
- ASCs also cannot overcharge Medicare patients for the IOL. Overcharging patients is a compliance issue.
Example: If a Crystalens® PC IOL is used in a cataract case and the cost for the lens is $1,100, the ASC will only receive $150 from Medicare for the IOL used in the surgery. That amount must be subtracted from the amount charged to the patient. Medicare allows only a modest markup on the IOL for handling ($25-$50 maximum).
Here’s an example of how to correctly charge a Medicare patient for a premium lens:
$ 1,100.00 Premium IOL cost
– $ 150.00 Medicare reimbursement for regular IOL
+ $ 50.00 ASC’s cost for handling of lens (markup)
Maximum amount the ASC can charge a Medicare patient
A Case for Compliance
Physicians can purchase and bring implants into ASCs for many other types of cases (for example, breast implants), so they may think they can do the same with premium lenses. This is not correct; however, because the IOL payment to ASCs is bundled into the cataract extraction CPT® code for Medicare patients. ASCs and ophthalmology practices should review their internal processes on the use of premium lenses to be sure they are compliant with Medicare guidelines.