Coding & Reimbursement

Postop Cataract Kit Update

By Suzanne L. Corcoran, COE

Cataract postop kits contain a variety of items that are useful to patients following cataract surgery, such as antibiotics and anti-inflammatory agents, eye shields, tape, sunglasses and lid scrubs. Historically, pharmaceutical companies supplied them to cataract surgeons as a promotional tool with samples of their medications. In turn, cataract surgeons provided them to their patients free of charge, frequently in a customized pouch with the name and logo of the practice imprinted on it.

However, this situation has recently changed. Here is what ophthalmologists need to know to keep up with the new guidelines behind postop kits.

Q. Why are most pharmaceutical companies no longer providing postop kits at no charge?

A. Many companies voluntarily comply with guidelines developed by the Pharmaceutical Research and Manufacturers of America (PhRMA). These guidelines describe how healthcare providers interact with pharmaceutical companies.

New PhRMA guidelines, effective Jan. 1, 2009, prohibit companies from providing non-educational and practice-related items to healthcare professionals (e.g., coffee mugs, pens, note pads, etc.). The guidelines do not preclude physicians from purchasing items from the pharmaceutical companies. The guidelines do state that it is appropriate to provide product samples for patient use in accordance with the Prescription Drug Marketing Act.

Q. What's different about postop kits that aren't free?

A. A surgeon may wish to charge a patient for a postop kit that he or she purchased. When the kit contains medications, state pharmacy laws govern this sale. If the kit does not contain medications, other state regulations may apply, such as those related to sales tax.

Check your own state laws to see what pertains.

Q. What stipulations are found in state pharmacy laws?

A. State pharmacy laws vary but many include detailed regulations concerning labeling requirements, record keeping, inspections, tax and licensure. Samples may not be sold.

Experience has shown that the administrative burden on physician practices to comply with state pharmacy laws frequently exceeds any possible revenue gain from the sale of pharmaceuticals. It's far less difficult to provide postop kits without medications and provide the patient a prescription to be filled at a pharmacy.

Q. May the surgeon charge patients for postop kits?

A. Yes. ASCRS/ASOA legal counsel, Robert M. Portman, of Powers, Pyles, Sutter & Verville, has indicated that: "With IOL manufacturers no longer providing free post-op cataract kits, many members are asking whether they can charge patients for these kits. The answer is yes, because these post-op kits are not covered by Medicare, physicians can provide them to patients for a reasonable price (e.g., cost plus reasonable mark up to cover administrative expenses, etc.). Physicians should not charge patients for any postop kits that they received for free from an IOL manufacturer or other source. Alternatively, physicians can avoid providing the postop kits to patients by writing a prescription for some or all of the items in the kit, and the patient can obtain them from a pharmacy."

Q. May the hospital or ASC bill for postop kits with medications dispensed for home use?

A. Yes, they may bill the patient for unopened medications. Medicare Part B does not cover drugs that are usually self-administered (Medicare Benefit Policy Manual Chapter 15, §50.5). The patient is responsible for the cost of the medicines. Medicare beneficiaries enrolled in Part D may be eligible for Medicare coverage of prescription medications.

In addition, some supplemental insurance plans (e.g., MediGap) offer drug benefits which pay for prescription medications.

Q. Does Medicare cover pharmaceuticals that are only partially used in the hospital or ASC?

A. Yes, as part of the facility fee. Medicare covers topical medications used in the operating room but does not pay for them separately; they are considered an incidental part of the hospital or ASC facility fee. The patient may not be billed.

Q. Some kits contain non-prescription sunglasses with UV protection. Does Medicare pay for them?

A. No. Medicare has a very limited benefit for eyeglasses. The benefit covers prescription glasses following cataract surgery, but does not include plano sunglasses. Sunglasses are considered a patient convenience item. As such, they are always the patient�s responsibility. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.