Coding & Reimbursement

Cataract & Refractive Surgery Combinations

By Suzanne L. Corcoran, COE

Modern cataract surgery techniques combine noncovered refractive services with cataract extraction. Surgeons achieve better patient outcomes, with reduced reliance on post-cataract eyeglasses due to reduced residual refractive errors. This month, we will attempt to clarify Medicare rules for services that are not covered.

Q. Does Medicare cover all items and services associated with cataract surgery?

A. Most items and services associated with routine cataract surgery are covered under Medicare's national policy (NCD 10.1). There are some things that are not covered, and the beneficiary is financially responsible for payment.

The Medicare law (Social Security Act, Title XVIII) limits health care coverage. Medicare does not pay for everything, even care that beneficiaries or their doctors have good reason to think patients need. Although Medicare beneficiaries may be disappointed, the fact is that Medicare does not cover routine eye care, specifically refractions, nor does it cover cosmetic surgery including most refractive procedures.

Q. When diagnostic tests are performed during the postoperative period, aren't they bundled with the surgery?

A. Usually not. The Medicare Claims Processing Manual (MCPM), Chapter 12 §40.1B, describes services not included in Medicare's global surgery package. For example, medically necessary “diagnostic tests” are outside of the package. So, a final refraction following cataract surgery is not bundled with the global surgery package and not covered by virtue of the Medicare law.

Q. But Medicare does cover post-cataract eyeglasses. Please explain.

A. Under Medicare law (Social Security Act, 1861(s)(8)), beneficiaries are covered for post-cataract eyeglasses following cataract surgery with an IOL. However, Medicare does not pay for the refraction to prescribe those eyeglasses.

Q. Must a Medicare beneficiary sign an ABN before receiving any noncovered items or services?

A. An Advance Beneficiary Notice of Noncoverage (ABN) is only required if something might be covered. However, items and services that are never covered by virtue of exclusions in the Medicare law do not require an ABN. Nevertheless, to avoid confusion, many practices obtain proof that the beneficiary accepts financial responsibility for noncovered items and services. Either an ABN or a Notice of Exclusion from Medicare Benefits (NEMB) may be used for this purpose. Also, get payment from the patient prior to rendering care.

Q. Are there any noncovered charges for evaluation and treatment of astigmatism at the time of cataract surgery?

A. In addition to refraction, corneal topography is very helpful for assessing corneal astigmatism hinted at by lensometry or detected by keratometry prior to cataract surgery. It is considered a covered test for indications such as post-penetrating keratoplasty, keratoconus, corneal dystrophy or keratopathy, but not for preoperative cataracts.

To achieve excellent unaided vision following cataract surgery, 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.

Q. What other diagnostic tests might be noncovered?

A. Screening for potential disease, such as macular degeneration or epiretinal membrane, using scanning computerized ophthalmic diagnostic imaging of the posterior segment (SCODI-P) is not covered because prophylactic testing is not a Medicare benefit, unless specifically authorized by Congress. In contrast, testing patients with a history of AMD is a covered service. Likewise, specular microscopy is a covered service under the Medicare national policy where clinically significant corneal pathology is present, as is B-scan for dense cataract.

Q. Some noncovered services are indispensable to the surgeon. Does the patient chose whether to have them?

A. Yes. Patients need to be fully informed about their care and any financial obligations. It's the patient's choice whether to proceed. If the patient places too many limitations or unreasonable expectations on the surgeon, the ophthalmologist has the option to refuse to provide care.

Q. Are there any noncovered services associated with conventional IOLs within an ambulatory surgery center?

A. The facility fee associated with performing limbal or corneal relaxing incisions for the surgical correction of corneal astigmatism is noncovered. Intraoperative wavefront aberrometry is likewise noncovered when performed to measure refractive errors during cataract surgery. OM

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