Coding & Reimbursement

Coding the PC-IOL Alternative

By Suzanne L. Corcoran, COE

Not every patient is a candidate for presbyopia-correcting IOLs, but many people want to minimize the need for eyeglasses for reading following surgery. As an alternative, some ophthalmologists offer patients pseudophakic monovision or blended vision. Here's the coding information you need to know about this procedure:

Q. What is blended vision?

A. A blended vision approach aims to provide excellent unaided vision following cataract surgery for presbyopic patients using conventional monofocal IOLs and targeting one eye for distance and the other for near. The surgeon aims for emmetropia in the dominant eye and myopia in the nondominant eye. The degree of spectacle independence depends on the patient's tolerance for myopic defocus and interocular defocus.

Blended vision is not appropriate for everyone; it is a compromise. Vision is not perfect either up close or far away, stereopsis is diminished, and spectacles may still be required for some tasks. Carefully selected and motivated patients, though, achieve high levels of satisfaction.

Q. How does the surgeon evaluate patient suitability for blended vision?

A. The surgeon administers a questionnaire designed to assess the patient's vision requirements in the normal activities of daily living, and the extent of the patient's desire for spectacle independence. Next, the surgeon performs a battery of preoperative tests to measure ametropias, ocular dominance, stereopsis and interocular defocus threshold. All of the tests are refractive in nature and the unit of measurement is diopters.

Suitability for blended vision depends on matching patient expectations to tolerance for imbalance between the two eyes.

Q. Who is financially responsible for these additional tests?

A. The measurement of refractive errors (ametropias) using a variety of techniques falls within the Medicare exclusion for refractions and is not a covered service (Medicare Claims Processing Manual, Chapter 21, §50.26.1). The beneficiary is responsible for payment.

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

A. 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 and to minimize confusion, the beneficiary 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. Determination of the refractive state of the eye is reported as CPT code 92015. A claim is not necessary, unless the patient specifically requests that you file. Perhaps the patient has a secondary insurance that he/she believes might cover the service. If you submit a claim, modifier-GY is used on Medicare claims to identify a service that is not a Medicare benefit. For blended vision, there are many more steps involved than a straightforward refraction using a phoropter. The additional tests, such as ocular dominance, stereopsis and interocular defocus threshold, make this an “unusual procedure” which is represented by the modifier 22 appended to the CPT code. Modifier 22 signals an atypical service and also permits an atypical charge.

Q. Is preoperative testing for blended vision bundled with any other services?

A. No. The National Correct Coding Initiative bundles apply only to covered services. Refractions are noncovered and not bundled with any other services.

Q. How often may these tests be administered?

A. All of these tests are bilateral in nature and are administered prior to the first cataract operation, although some of them may need to be repeated prior to the second cataract operation.

Q. What is the value assigned to CPT 92015?

A. Medicare does not pay for refractions. However, the 2011 national Medicare Physician Fee Schedule assigned 0.79 RVUs to CPT 92015, which corresponds to $26.84. Check the local marketplace to assess the going rate in your area.

Q. Are there other charges associated with blended vision?

A. Sometimes. To achieve excellent unaided vision with blended vision, corneal astigmatism must be minimized. The surgical correction of pre-existing astigmatism is another noncovered service that should be considered for patients with more than 0.75 D of cylinder. OM

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