Ophthalmology and Optometry Coding Alert

Medicare won't cover the full cost, but this expert advice will help you get the reimbursement you deserve

After cataract surgery, an ophthalmologist inserts a Crystalens intraocular lens to correct a Medicare patient's presbyopia. Can you code for the physician's services and supplies? The answer is yes--with these exceptions.

Presbyopia-correcting (P-C) IOLs can improve the quality of life for cataract patients who would otherwise need to rely on bifocals for near vision. Medicare typically covers the insertion of a conventional, clear IOL to replace the cataract-stricken lens that the ophthalmologist removes. In May, Medicare ruled that cataract patients who request a P-C IOL, such as the Crystalens or AcrySof RESTOR lenses, can have them--if they are willing to pay the extra cost.

The problem: Medicare only partially covers P-C IOLs, says Marco Ortiz, manager at Harvard Eye Associates in Laguna Hills, Calif. Although it does consider a conventional IOL medically necessary after cataract surgery, there is "no benefit category" for the presbyopia correction itself.

"A single presbyopia-correcting IOL essentially provides what is otherwise achieved by two separate items: an implantable conventional IOL (one that is not presbyopia-correcting), and eyeglasses or contact lenses," states CMS Ruling 05-01, released in May 2005. Medicare does cover one pair of eyeglasses or contact lenses for each patient following cataract surgery, but, "although presbyopia-correcting IOLs may serve the same function as eyeglasses or contact lenses furnished following cataract surgery, IOLs are neither eyeglasses nor contact lenses. Therefore, the presbyopia-correcting functionality of an IOL does not fall into the benefit category and is not covered."

This leaves coders with a unique dilemma: how to code for each portion of the IOL. Report Cataract Codes for Covered Portion Although Medicare has no immediate plans to establish new codes for the presbyopia-correcting (non-covered) portion of the P-C IOL, coding for the portion that Medicare does cover is fairly straightforward: Code for "a conventional IOL, regardless of whether a conventional or presbyopia-correcting IOL is inserted," directs an Aug. 5, 2005, CMS change request, "Instructions for Implementation of CMS Ruling 05-01: Presbyopia-Correcting Intraocular Lens."

For a cataract surgery with a P-C IOL insertion, report one of the following to Medicare:

• 66982--Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary  posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage

• 66983--Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure)

• 66984--Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification). Warning: Although selecting, inserting and vision-acuity testing of a P-C IOL does involve more pre- and postoperative [...]