coding for reimbursement
Coding for Pseudophakic Monovision Testing

Not every patient is a candidate for presbyopia-correcting IOLs, but many people want to minimize the need for postcataract eyeglasses. Just as some phakic patients are happy with monofocal vision using contact lenses, "pseudophakic monovision" may be an option for some cataract patients.

Q. What is pseudophakic monovision?

A: This option aims to provide excellent unaided vision following cataract surgery for presbyopic patients by using monofocal IOLs and targeting one eye for distance and the other for near.

The degree of spectacle independence depends on the patient's tolerance for myopic and interocular defocus. This postoperative result is not for everyone; monovision is a compromise. Vision is not perfect up close or far away, stereopsis is diminished and spectacles may still be required for some tasks.

Q. How does the surgeon evaluate patient suitability for pseudophakic monovision?

A: Suitability for pseudophakic monovision depends on matching patient expectations to tolerance for imbalance between the two eyes. A questionnaire can assess the patient's visual requirements and the extent of the patient's desire for spectacle independence.

Q. Does Medicare cover preoperative testing for pseudophakic monovision?

A: No. While the surgeon performs a battery of tests to measure ametropias, ocular dominance, stereopsis and interocular defocus threshold, they are not covered by Medicare and/or other third-party payers (Medicare Claims Processing Manual, Chapter 21, §50.26.1). Medicare does not pay for refractions, but the 2006 Medicare Physician Fee Schedule assigned 1.88 RVUs to CPT 92015, which corresponds to $71.25.

Q. Does the beneficiary need to sign an Advance Beneficiary Notice (ABN) for preoperative testing?

A: No, an ABN is not required for services that are not a Medicare benefit or are excluded from coverage by statute. However, in the interest of full disclosure, the patient should be advised in advance of financial responsibility; a Notice of Exclusion from Medicare Benefits (NEMB) is appropriate for this purpose. For non-Medicare beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) performs the same function.

Q. How should preoperative testing be coded on claims for reimbursement?

A: A claim is not necessary, unless the patient specifically requests that you file. Perhaps the patient has secondary insurance that he/she believes might cover the service. Refraction is reported with CPT code 92015. Modifier -GY is used on claims to identify a service that is not a Medicare benefit. Since refraction is accompanied by a battery of related tests for pseudophakic monovision, a single charge should be made for "refraction plus" and modifier -22 (unusual procedural services) may be appended to the CPT code. Modifier -22 signals an atypical service and also permits an atypical charge.

Q. Is preoperative testing for pseudophakic monovision bundled with any other services?

A: No. Bundles apply to covered services only.

Q. How often can these tests be administered?

A: All of these tests are administered prior to cataract surgery, and some of them may need to be repeated prior to a
second surgery.

Q. Are there other charges associated with pseudophakic monovision?

A: Sometimes. To achieve unaided vision with pseudophakic monovision, astigmatism must be minimized. The surgical correction of pre-existing astigmatism is another noncovered service, which should be considered for patients with more than 0.75 D of cylinder.

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. Her company publishes a monograph, Medicare Reimbursement for Surgical Correction of Corneal Astigmatism, and has sample forms of the NEMB and NEHB on its Web site, which can be accessed at www.corcoranccg.com.