coding & reimbursement
Medicare and Presbyopia-Correcting IOLs
Guidance for Cataract Surgery's Latest Generation of IOLs

By Suzanne L. Corcoran, COE

In May, CMS issued a ruling (No. 05-01, www.cms.hhs.gov/) that Medicare beneficiaries may now choose cataract surgery with a presbyopia-correcting IOL and pay the extra charges. Exciting, but also challenging, the new IOLs are more expensive and require more resources from the surgeon. The next questions, of course are how do you document and how do you bill?

Q: Does Medicare cover cataract surgery with the new IOL? Yes, if a patient has a cataract that falls within coverage criteria. Carriers publish policies on cataract coverage. An incipient cataract that does not meet these criteria is considered non-covered. This does not preclude the patient from having the procedure, but the patient must pay all costs.

Q: How does Medicare treat cataract surgery with these IOLs? Medicare is continuing to pay for standard cataract surgery with a conventional IOL. Presbyopia correction entails charges for added services and a deluxe IOL component not covered by Medicare. These are the beneficiary's responsibility. The surgeon and the hospital or ambulatory surgery center (ASC) will ask the beneficiary to pay for those items and services. We call this "patient-shared billing."

Q: Should I ask the patient to sign an Advance Beneficiary Notice (ABN)? The CMS transmittal 636 (www.cms.hhs.gov/manuals/pm_trans/R636CP.pdf) says no. Because the deluxe component of the IOL and the extra services provided by the surgeon are related only to the correction of presbyopia, which is statutorily non-covered, an ABN is not necessary. Although not required, CMS encourages the use of a Notice of Exclusion from Medicare Benefits (NEMB) to notify the patient of the non-covered charges and document acceptance of financial responsibility. You can obtain a NEMB copy form from the Corcoran Consulting Group Web site that can be accessed at www.corcoranccg.com.

Q: How should I code the extra services and deluxe component of the IOL on my claim? You do not need to put these charges on the claim. The CMS transmittal states, "No new codes are being established at this time to identify a presbyopia-correcting IOL or procedures and services related to a presbyopia-correcting IOL." If you choose to include these charges on your claim, HCPCS code A9270 (non-covered item or service) coupled with modifier GY (statutorily non-covered) may be used. Some patients may also have secondary insurance that they believe will cover the extra charges, and request that you file the claim with Medicare for a denial.

For non-Medicare payers and for internal tracking, the hospital or ASC may use V2797 (vision supply, accessory) to describe the presbyopia-correcting function of the IOL. The surgeon can use S9986 (not medically-necessary service) to describe the extra refractive services.

Q: How do I determine my charges for the extra services and costs associated with the IOL? The hospital or ASC should determine the cost of obtaining the presbyopia-correcting IOL and deduct the Medicare reimbursement for a standard lens that is included in the facility fee. For example, Medicare includes $150 as the cost of a standard IOL in the ASC facility fee. The patient's charge will be the difference of the ASC's cost of the IOL and the $150 paid by Medicare.

The surgeon should start by assembling a listing of the extra services and resources expected to be required for presbyopia correction. Assign values to each of the items on the list, add them all together, and use that to determine a charge. Because this is a refractive procedure, market forces will affect the charge, and you will need to determine what the going rate is in your area. We recommend that you establish one fee and use that for all patients who request cataract surgery with one of these new IOLs.

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