Coding & Reimbursement

New Toric IOL Options

Billing and coding toric IOLs for cataract patients.

By Suzanne L. Corcoran, COE

Ophthalmologists continue to expand their offerings of vision enhancements to cataract patients. In 2005, Medicare first allowed patients to elect a presbyopia-correcting IOL (P-C IOL) and pay out of pocket for the upgrade. Now, Medicare has extended the same concept to toric IOLs.

Q. What is a toric IOL? A toric IOL is designed to provide correction for both sphere and cylinder during cataract removal for patients with pre-existing corneal astigmatism. It is positioned in the posterior chamber of the eye, replacing the natural lens.

Q. How does Medicare differentiate between types of IOLs? For payment purposes Medicare distinguishes between conventional IOLs, new technology IOLs (NTIOLs), P-C IOLs and toric IOLs.

For conventional IOLs, beneficiaries pay only the obligatory co-payment and deductible.

For an NTIOL, Medicare allows $50 to an ASC above and beyond the payment for a conventional IOL, which is likewise subject to a co-payment and deductible but entails no additional out-of-pocket expense.

P-C IOLs, and now toric IOLs, incorporate a "deluxe" component for the presbyopia-correcting functionality that is non-covered and requires an additional payment by the beneficiary. CMS Ruling 1536-R defines this feature as non-covered.¹

Q. What is the charge for astigmatism-correcting IOLs? There are two parts to the charge: one part covered, and one part non-covered. As a point of reference, Medicare has valued IOLs at $150 in its determination of ASC payment rates, so the covered portion is part of the standard facility fee. Therefore, the non-covered charge to upgrade to a deluxe IOL is any additional charge beyond $150. For hospitals, the allowance for a conventional IOL may depend on the hospital’s past charge history, and $150 may not be the correct answer; check with the facility. In either case, any mark-up on the IOL should be very modest to account for shipping, handling and sales tax, etc.

Q. For P-C IOLs, we have a charge for non-covered services. Does the same concept apply to the toric IOLs? The Medicare program allows beneficiaries to purchase an upgrade from a conventional IOL to an astigmatism-correcting IOL and pay additional charges beyond those associated with standard cataract surgery. They might include:

• Refraction
• Corneal topography for pre-existing astigmatism
• Wavefront aberration testing
• Marking the axis of astigmatism on the eye at the outset of cataract surgery
• Refractive keratoplasty for residual astigmatism (e.g., limbal relaxing incision)
• At the surgeon’s discretion, these charges may be itemized or consolidated in a package.

There is no extra charge for more extensive IOL calculations. IOL power determination for a toric IOL requires selection of two parameters: sphere and cylinder. The professional component of biometry (76519-26 or 92136-26), which includes IOL power determination, is covered by Medicare so the beneficiary may not be charged extra.

Q. Should we get the patient to sign an ABN? No. Patients must be notified in advance of financial responsibility, and agree to pay for the non-covered items and services associated with a toric IOL. For Medicare beneficiaries, CMS strongly recommends the use of a Notice of Exclusion from Medicare Benefits (NEMB) to clearly identify the non-covered items and services, as well as the associated fees. The facility and surgeon should each execute a separate NEMB. Do not include these forms with the claim for reimbursement.

For non-Medicare beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) serves the same purpose as a NEMB. NEMB and HEHB forms are available on the Corcoran Consulting Group Web site (listed below). OM

Reference

1. Centers for Medicare and Medicaid Services. Ruling No. CMS-1536-R. Available at: www.cms.hhs.gov/rulings/downloads/cms1536R. pdf. Accessed February 21, 2007.