Above and Beyond
Why not get paid for your refractive cataract surgery skills and services?
BY DESIREE IFFT, EXECUTIVE EDITOR

Now that the results of cataract surgery can look so much like the results of refractive surgery, it may be time to separate them -- in your mind and in the minds of your patients, that is.

Consider this: One of the most common times patients sue cataract surgeons is when an error in IOL power calculation results in an increased dependence on glasses. So, as more patients come to assume that all cataract surgery routinely eliminates the need for glasses, you may be at increasing risk for malpractice claims.

ILLUSTRATION: SHARON & JOEL HARRIS

Furthermore, as you know, Medicare does not pay for cosmetic surgery and rarely covers refractive surgery, which means anything you do surrounding cataract surgery specifically to reduce a Medicare beneficiary's dependence on glasses is not covered. You don't get reimbursed for addressing what could be your biggest liability. And when you provide your cataract patients with excellent uncorrected vision, you're not compensated by Medicare for the time, resources and advanced skill that make it possible.

A new way of addressing these issues has emerged. Some practices are offering "refractive cataract surgery" as an optional alternative to "cataract surgery." "Refractive cataract surgery" has an additional fee, paid by the patient, for keratoplasty and the associated diagnostic tests. Practices are within their rights to charge interested patients for this "deluxe" service, as long as they don't violate Medicare regulations. In this article, Kevin Corcoran, C.O.E., C.P.C, F.N.A.O., explains how to comply (See "Following the Rules," on page 36.) and surgeons who've adopted this approach talk about how it works.

Two Types of Cataract Surgery

"Surgeons who approach cataract surgery as a 'gestalt,' not just as removing the clouded lens and putting in an IOL, have a wider spectrum of factors to contend with," says Corcoran. "It's a different way of looking at the procedure. At that point, cataract surgery is really two things: managing the problem that is created by the cataract itself, but also fulfilling the patient's desire to be as free from glasses as possible."

Many of the tests and procedures you use toward that goal, such as astigmatic keratotomy (AK) for pre-existing astigmatism and the associated corneal topography, aren't Medicare-covered services in this context; they're refractive services, which means the patient can elect to pay for them out-of-pocket.

The form this concept is taking is that surgeons present to patients the two types of cataract surgery available to them. One is surgery without an attempt to reduce dependence on glasses. The other is with every attempt to reduce dependence on glasses. Attached to the second option is an extra fee, which covers whatever is necessary to achieve the uncorrected vision target established by the surgeon and the patient. Some practices have set their fee at a few hundred dollars per eye; in other markets, patients are paying closer to $1,200 per eye. Should patients need an additional refractive procedure, such as CK, LASIK or PRK, to fine-tune their results within a certain amount of time, it's typically included in the fee.

When Medicare patients select refractive cataract surgery, you are not required to have them sign an Advance Beneficiary Notice; however, they should sign a waiver stating that this is a noncovered service and they are responsible for payment. (For an example, see "Following the Rules," on the previous page.) In addition, you should create a special informed consent document that combines your standard surgical risks explanation with wording that addresses these key points:

► the refractive surgery is an option and not medically necessary

► the possibility exists for resulting vision to be the same whether the patient selects refractive cataract surgery or standard cataract surgery

► spectacle wear can be greatly reduced with refractive surgery but may still be required for some tasks.

Legal advisors have suggested that the waiver or informed consent require the patient to rewrite key phrases to show that they've read them.

Making these points and planning and explaining each patient's treatment is very time-consuming, but some surgeons, especially at the outset, handle all discussions with patients themselves. This allows them to gauge firsthand how interested their patients are in refractive cataract surgery, and ensures they're properly selected and educated based on their refractive error.

Some patients will not be good candidates for the refractive cataract surgery option because they expect total freedom from glasses and are unwilling or unable to understand that some compromises are involved. If a patient keeps asking why he has to have less-than-perfect uncorrected vision for a certain task in order to be spectacle-free for another, he is not a good candidate.

You Can Start Conservatively

Three months ago, Larry Patterson, M.D., of Crossville, Tenn., began presenting his practice's refractive cataract surgery option to patients. "The biggest challenge right now is helping them to understand this concept," Dr. Patterson says.

"We're only presenting the option to patients who answer 'would you be interested in not having to wear glasses all the time?' with an enthusiastic 'yes!' Some people's eyes really light up; others actually like their glasses for various reasons or just aren't that interested.

"Right now, we consider our ideal candidates to be those highly motivated patients who also have bilateral cataracts that both need to be removed." When the cataracts are bilateral, surgery on the second eye is performed a week or two after the first so balanced vision can be achieved in a relatively short period of time.

Patients with other pathology, such as glaucoma or AMD are excluded. "In these cases, we just have to focus on their basic visual rehabilitation," Dr. Patterson says. "So far, a minority of our patients are accepting it, but we'll see if that changes."

Practices that have had formal refractive cataract surgery programs in place for a longer time report that as many as 75% of their patients opt for the deluxe package. They tend to present the package to most patients and were often surprised at the high number of patients over age 60 who choose it.

The concept of refractive cataract surgery as a unique entity can take time to catch on, says Stephen Wiles, M.D., of Kansas City, Mo. He has been charging astigmatic patients to perform limbal relaxing incisions (LRIs) for about 5 years. During that time, he's found that patients who could benefit from astigmatic correction, and could afford it, were more than willing to pay for the luxury. Based on that experience, he plans to begin offering a more comprehensive upgrade package of services that will include compensation for his time, expertise and all noncovered refractive tests and procedures necessary to reduce dependence on glasses.

Louis D. "Skip" Nichamin, M.D., of Brookville, Pa., has helped to develop LRIs and has been performing them for years, but he's never charged for them. "I believe a surgeon should charge for what he or she does for a patient," Dr. Nichamin says. "But I've been doing LRIs for so long, it's just easier for me to provide them as a value-added service instead of instituting a new charge. I do charge patients a fee for the pre-op corneal topography. Ninety-nine percent of them accept that, and it has helped to blunt the increased overhead that's involved in doing the LRIs."

Dr. Nichamin also employs bioptics frequently in his practice. When he uses a keratorefractive procedure following cataract surgery to further refine vision, patients pay out-of-pocket for the second procedure. They are informed of the possibility and sign the waiver explaining the fee prior to undergoing cataract surgery.

Surgical Skill Essentials

No matter what combination of the many possible techniques a surgeon utilizes to give patients optimal uncorrected vision, to be able to deliver the desired results, he or she must be able to:

► develop IOL calculation accuracy to true state-of-the-art levels, cited as within 0.25D of the target, or within 0.50D of the target for degrees of correction above 10D. Precise biometry, by using either the immersion method or the Carl Zeiss Meditec IOLMaster, is essential.

► achieve under 1D of astigmatism for any patient. If that's not possible, the patient is not a good candidate.

► reduce the capsular rupture rate to lower than the average 3% of cases, preferably close to zero. One way to accomplish this is by using a supracapsular technique.

► address presbyopia to the patient's full satisfaction. This doesn't mean the patients will be able to see everything put in front of them. It means they understand their refractive goal will involve compromises but accept them in order to accomplish that goal. Some surgeons said their preferred means to this end are bilateral multifocal lenses for appropriately selected patients or blended vision with bilateral monofocal implants.

Prelude to the Future?

Several of the surgeons interviewed foresee refractive lens exchange as a much bigger part of their practices in the future, and say that adding refractive surgery as a deluxe alternative to traditional cataract surgery is a step in that direction.

Many said it's key to underpromise and overdeliver. And as Dr. Wiles advises: "You have to believe in what you're doing and believe that you are providing valuable services crucial to patients' vision and beyond the scope of what Medicare covers."

Following the Rules

According to coding and reimbursement expert Kevin Corcoran, C.O.E., C.P.C, F.N.A.O., because Medicare covers cataract surgery and does not cover refractive surgery, "beneficiaries who want to pay for 'extra' refractive services can do so. It is acceptable for physicians to provide a 'deluxe' service." He advises practices taking this approach with Medicare patients to: ► Obtain patients' signatures on a waiver stating that the refractive tests and procedures are not covered benefits and they are responsible for payment. The basic form that appears here, which was written by CMS but never formally adopted, is suitable for this purpose. The waiver can cover anything that is appropriate for refractive surgery. For example, if a patient elects to undergo limbal relaxing incisions at the time of cataract surgery to correct pre-existing astigmatism, after "Medicare will not pay for:" you would write "limbal relaxing incisions and corneal topography prior to limbal relaxing incisions." Then you would check the "cosmetic surgery" box to indicate why the services aren't covered. Also, on this patient's CMS-1500 claim form, you could use procedure code 66999 with the modifier -GY to notify Medicare that you have performed an excluded procedure. This is not mandatory, but is recommended in the interest of accurate record-keeping. You could include the relaxing incision on the claim form so that the Explanation of Benefits shows that the procedure isn't covered, but that's not required either. ► It's in your best interest to list on your waiver all tests involved with a patient's refractive surgery diagnostic work-up (e.g., corneal topography, pachymetry, and in some cases, specular microscopy). Doing so makes it clear what the patient is paying for and reduces the possibility of confusion at some later time over what was provided. ► Avoid portraying any noncovered refractive service as a "freebie" to encourage cataract surgery. This might be considered as illegally incentivizing a patient to have cataract surgery in your practice.