Coding & Reimbursement

Cataract Surgery, Comanagement & CMS

By Suzanne L. Corcoran, COE

As refractive cataract surgery becomes more popular, questions about comanagement become more frequent. Here is what you need to know for Medicare billing.

Q. Is comanagement permitted when patients undergo cataract surgery with premium IOLs?

A. Cataract surgery that includes implantation of a presbyopia-correcting IOL (P-C IOL) or astigmatism-correcting IOL (toric IOL) treats two conditions: one medical — cataract-impaired vision — and the other refractive — presbyopia or astigmatism. Treatment of the medical condition is covered, while the refractive treatment is noncovered and payable by the patient. These lenses are often referred to as “premium” IOLs.

Comanagement of these cases is permitted because Medicare's guidelines for comanagement of postsurgical care do not depend on the type of IOL used. Follow existing co-management protocols for the covered portion of these procedures.

Q. May the noncovered physician services be comanaged?

A. Yes. While Medicare did not address this in any of its rulings regarding premium IOLs, both physicians can participate in providing the non-covered services that accompany the use of P-C or toric IOLs. Typically, a package of refractive services is identified rather than presenting the patient with an a la carte list of services.

Q. What is included in the package of noncovered physician services?

A. The package of noncovered physician services is comprised of those additional tests, exams and procedures that are not related to the performance of traditional cataract surgery with an IOL, or are defined as noncovered anyway (e.g., refraction and refractive procedures). Each surgeon will determine what services to provide, but the list might include the following, among others: refraction, contact lens trial fitting, wavefront aberrometry, corneal topography and pachymetry associated with refractive surgery, refractive keratoplasty and, in extraordinary cases, IOL exchange. The physician may also feel that an extended follow-up to monitor refractive error is warranted.

Q. How is the value of this package determined?

A. As a starting point, the surgeon should refer to his existing professional fee schedule for these tests, exams and procedures. The value of the package will be the sum of the component charges weighted according to the likelihood of delivering that service.

Q. In a comanagement situation, how is the value of this package divided between the two physicians?

A. Medicare's comanagement rules only provide instruction for covered services, so it is unwise to extrapolate Medicare's 80/20 concept to the noncovered physician services. Instead, the receiving physician should make a discrete charge(s) for services rendered, consistent with usual and customary charges (e.g., exams, refractions).

In anticipation of the comanaged care, the surgeon should reduce his package charge by an amount that represents services he will not render. This way, comanagement will not result in the patient paying much greater fees for the noncovered care.

Q. Who should obtain a financial waiver in reference to noncovered services?

A. Both the surgeon and the receiving physician are strongly encouraged (although not required) to obtain financial waivers in connection with providing noncovered services to Medicare beneficiaries receiving a P-C or toric IOL. The waiver may take many forms, as long as it is clear.

A Notice of Exclusion from Medicare Benefits (NEMB) is our preferred approach. The NEMB should clearly identify which services the patient is expected to pay for, the reason why the services are not covered, and the associated professional fees. Alternatively, Medicare's Advance Beneficiary Notice of Noncoverage may be used. We prefer the NEMB because it engenders less confusion.

Q. May the surgeon collect a single fee for all of the noncovered services and pay the referring doctor for his services?

A. We don't recommend it. To avoid any appearance of “payment for referrals” (a.k.a. kickback), each provider should charge and collect for his respective services. For the patient's convenience, the surgeon may act as a collection agent for the comanaging physician — the patient makes out two checks (i.e., one for the surgeon, and one for the co-managing physician). OM

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