As you know, patients with cataract often have astigmatism as well. But today, a patient with both an operable cataract and astigmatism can reduce or eliminate the need for corrective lenses by undergoing the combined procedure of cataract extraction (with intraocular lens implantation) and astigmatic keratotomy (AK). AK can be performed using any of several techniques, including corneal relaxing incisions (CRI) and wedge resection.

Resolving both problems in a single procedure is obviously an attractive option for patients. However, there are several considerations to be addressed before scheduling surgery, in-cluding the issue of reimbursement.

Here, we’ll discuss how reimbursement works when this procedure is performed on a Medicare beneficiary.

Medicare will reimburse you for a wide variety of services, including surgery, but there are indications for and limitations of coverage.

Two limitations are particularly relevant here:

• First, Medicare only reimburses covered services, and refractive surgery doesn’t usually fall into that category. The exception is when refractive surgery is done to repair a surgical complication (from a prior operation) or astigmatism due to trauma.
• Second, astigmatism following surgery is usually pre-existing astigmatism, rather than iatrogenic astigmatism – i.e., astigmatism that was induced by the surgeon – making it ineligible for Medicare reimbursement.

The rule regarding pre-existing astigmatism is clearly stated in the Medicare Carriers Manual: "Keratoplasty for the purpose of refractive error compensation is considered a substitute or alternative to eye glasses or contact lenses, which are specifically excluded. Keratoplasty to treat refractive defects (is) not covered."

Under most circumstances, complications of cataract surgery are rare – they occur in less than 3% of cases. Nevertheless, when such complications do occur, Medicare will usually reimburse you for correcting the problem, and this includes surgically-induced astigmatism.

The Current Procedural Terminology (CPT) handbook describes two procedures that can be used to correct surgically-induced astigmatism:

• Corneal relaxing incision (coded 65772)
• Corneal wedge resection (coded 65775)

In general, relaxing incisions are used to correct small amounts of astigmatism while wedge resection is used to correct greater amounts of astigmatism.

The CPT handbook doesn’t contain any procedure codes for correction of pre-existing astigmatism that wasn’t surgically induced. You have to use a miscellaneous code, such as 66999 (unlisted procedure, anterior segment of the eye), to describe the surgery when your office submits a claim –even though Medicare won’t pay for it.

Medicare claims for AK should include astigmatism as the primary diagnosis code, as well as a supplemental diagnosis to further describe the reason for the procedure.

Reasons for the procedure could include:

• regular astigmatism existing concurrently with anisometropia
• irregular astigmatism in patients with keratoconus
• astigmatism resulting from prior surgery that has proven to be uncorrectable by conventional means, such as eyeglasses and contact lenses. (See "Diagnoses and ICD-9 Codes" at the end of this document for more examples of related conditions.)

It may be necessary to submit additional information that supports the claim, such as the operative report, pre- and postoperative refraction, corneal topography and other attempted treatments such as glasses or contact lenses.

When performing AK under conditions that Medicare may determine to be "not medically necessary," the Medicare Carriers Manual requires you to notify the patient – in writing – that Medicare is likely to refuse payment for this service. The patient must understand that he’ll be required to cover the cost of the procedure, and he must sign the form to indicate acceptance of these conditions.

For this reason, you should provide a physician notice form, also known as a waiver (see sample "Physician Notice" at the end of this document). This form advises the patient that this service may not be covered by Medicare, and that he’ll be responsible for the charges associated with the AK procedure. By signing the form, the patient agrees to pay and elects to proceed.

To indicate that you’ve complied with the notice requirements, you should add the modifier -GA to procedure code 66999 on the HCFA-1500 claim form.

In some cases, patients have supplemental insurance that may cover the charge for the AK. For that reason, the inclusion of the AK procedure on the claim form (coded with the -GA modifier) is useful; the explanation of benefits will show that the procedure wasn’t covered by the primary insurance.

The hospital outpatient department (OPD) or ambulatory surgery center (ASC) may also charge for AK. Whether or not these charges are reimbursed by Medicare also depends on the origin of the astigmatism:

• In a typical case involving pre-existing astigmatism, Medicare won’t reimburse either the OPD or ASC. The patient will be responsible for payment of these charges as well.
• If the AK is performed to correct surgically-induced astigmatism, the OPD would be reimbursed by Medicare, but the ASC would not. (Neither 65772 nor 65775 is included in the list of procedures for which an ASC facility fee is payable under Medicare’s current regulations.) Furthermore, since Medicare-approved ASCs are all participating, the patient can’t be balance billed by the ASC for a procedure that is covered for the surgeon.

Cataract surgery is a covered benefit under Medicare regulations, provided that there’s adequate medical necessity to justify the procedure. However, if you offer "free refractive surgery" as an inducement to have cataract surgery, Medicare will object, and there could be serious legal consequences. Conversely, if you present AK as an incidental part of the cataract operation, the legal stigma is removed.

For many ophthalmologists, there are already enough surgical bundles that serve to inhibit reimbursement; this is one time when you can at least choose your own fate.

AK alone, or in combination with cataract surgery, is an excellent way to restore uncorrected vision. Because it’s a simple and increasingly safe and effective procedure, it’s an option many of your patients will be interested in pursuing. At the same time, most cases of astigmatism are pre-existing, rather than surgically induced, so the cost of AK won’t be reimbursed by Medicare. That means that you and the facility can both charge the patient for the surgery.

The bottom line is that AK provides a means to enhance patient satisfaction and practice revenue at the same time – and that’s always a good thing.

Special note: The information in this article is only a general discussion of Medicare reimbursement for astigmatic keratotomy. This isn’t an official source, or a complete guide to all matters pertaining to reimbursement.

In fact, you may encounter local variations among carriers that aren’t described here. For that reason, we strongly encourage you to review official instructions from the Health Care Financing Administration and their Medicare carriers.

This patient had an increase of 1.50D of astigmatism following cataract surgery. Because the astigmatism was surgically induced, you would seek reimbursement from Medicare for this procedure.

In this case, the patient presents with 2.00D of astigmatism postoperatively, but the astigmatism wasn’t surgically induced. For that reason, you should seek reimbursement from the patient for the AK. Prior to the operation, and during the informed consent, the patient should be asked to sign a form that indicates acceptance of the financial responsibility for the AK. (See sample "Physician Notice" at the end of this document.)

This patient presents for cataract surgery with significant astigmatism in the preoperative refraction and elects to have AK at the time of cataract surgery. In this case, Medicare will reimburse for the cataract surgery, but the patient must be respon-sible for payment for the AK procedure.

These are some of the ICD-9 codes that can be associated with AK.