coding & reimbursement
Billing for Refractive Surgery?
Under certain circumstances, it is possible.

In general, surgery to correct refractive error is considered an elective procedure and not reimbursed by Medicare. However, if cataract surgery results in anisometropia, further surgery may be billable.

Q: Following cataract surgery, some patients still have refractive errors. What are the treatment options? Refractive errors following cataract surgery can usually be corrected with eyeglasses or contact lenses. Occasionally, however, the refractive error is large enough to create anisometropia. If this can't be corrected with glasses or contact lenses, then additional surgery is warranted and may be covered by Medicare.

Anisometropia is clinically significant when the difference between visual acuity in the right and left eyes is more than 2 diop-ters. Surgery is indicated when:

► the patient complains of significant symptoms (diplopia, difficulty reading, poor depth percep- tion and intolerance of glasses)

► the symptoms adversely affect the patient's lifestyle

► the anisometropia can't be satisfactorily corrected with eyeglasses or contact lenses.

Two options are available when surgical intervention is warranted:

► The surgeon can remove the problematic IOL and implant a new one. An IOL exchange should be billed using CPT code 66986. Pertinent diagnosis codes include 367.31 (anisometropia), 368.2 (diplopia), and 996.53 (complication due to IOL).

► The surgeon can implant a "piggyback" lens on top of the first IOL. This should be billed using CPT code 66985 and the diagnosis codes noted above. CPT code 66985 is usually associated with a diagnosis of 379.31 (aphakia) so additional information may be required to get the claim paid.

Q: What if the patient simply wants to eliminate eyeglasses, but doesn't meet the criteria for Medicare coverage? For patients with adequate distance vision who desire improved near vision, a low-diopter piggyback IOL is an option. However, this procedure would be considered refractive and not covered by Medicare. In this situation the patient is responsible for all charges, including both the surgeon's and the facility's fee.

Medicare considers refractive surgery to be cosmetic and therefore noncovered by statute. For that reason, it doesn't require that a claim be filed. However, the patient may request that you file a claim. Some patients have supplemental insurance that would cover this kind of surgery, but a denial from Medicare is required in order for the coverage to apply.

If you do file a Medicare claim in this situation, include modifier -GY on the claim to indicate that it should be denied.

Q: If billing for surgery to relieve anisometropia, should I have the patient sign a Medicare advance beneficiary notice (ABN)? No, because:

► An ABN isn't required for statutorily noncovered services.

► When you have a signed ABN you're required to submit a claim using modifier -GA, which would probably result in an erroneous Medicare payment.

To avoid confusion and bad feelings later, a written notice to the patient is advisable. However, you should use a non-Medicare waiver for this purpose instead of an ABN. (You could modify an ABN form for this purpose.)

Q: What fee can I charge for this surgery? Since refractive surgery is statutorily noncovered, Medicare's fee schedule doesn't apply. You can set your fee at any amount that is acceptable to both you and the patient.

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.