Coding & Reimbursement

Coding for Laser Cataract Surgery

By Suzanne L. Corcoran, COE

Laser cataract surgery is a hot topic these days, exciting for surgeons and patients alike. What are the reimbursement issues you need to consider?

Q What has Medicare published about reimbursement procedures for femtosecond lasers and cataract surgery?

A To date, the Centers for Medicare and Medicaid (CMS) have not published any specific guidance. The American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery published a joint paper in January, outlining when it is and is not appropriate to bill Medicare beneficiaries for use of the femtosecond laser.

Q What does Medicare cover in the global fee for cataract surgery?

A First, keep in mind that Medicare covers medically necessary cataract surgery with implantation of an IOL, regardless of the technology used. Medicare’s National Coverage Decision (NCD 10.1) includes the following in the allowed amount for cataract surgery: a comprehensive exam, an A-scan (or ocular coherence biometry) to determine the IOL power, a B-scan for a dense cataract, the intraoperative services, and 90 days of postoperative care.

Medicare makes no distinction between a diamond knife or cystotome, and a femtosecond laser used during the covered surgery. The surgeon may use any device she or he wishes. However, if the only service being provided is medically necessary cataract surgery, then the surgeon may not charge the patient any additional amount.

Q When may we charge the patient extra for these services?

A One situation is refractive lens exchange. When the patient does not have a cataract, or has an early cataract that does not meet medical coverage criteria, a lens exchange is purely refractive and payable entirely by the patient. This includes the surgeon’s fee, the facility fee, any anesthesia and any related testing.

Second is surgical correction of corneal astigmatism (SCOCA). Medicare does not cover the refractive procedure, with rare exceptions. Regardless of the methodology used, the patient pays. There are various kinds of SCOCA, including limbal or corneal relaxing incisions, astigmatic keratotomy, photorefractive keratectomy, and LASIK/LASEK. Use of the femtosecond laser facilitates some of these procedures. Because they are refractive, larger charges for use of the femtosecond laser are permissible.

When SCOCA is performed in conjunction with covered cataract surgery, the extra charge to the patient must be reasonable and readily identifiable. No additional charge to the patient for covered cataract surgery is permitted.

Premium IOLs represent another situation in which the practice may make additional charges to the patient. As we have discussed previously in this column, additional charges to the patient are permissible when the surgeon implants a presbyopia-correcting or astigmatism-correcting IOL. These lenses provide a refractive benefit in addition to medically necessary cataract surgery. Tests and other professional services associated with presbyopia or astigmatism are billable to the patient, as is the overage for the lens itself (which is charged by the facility).

However, CMS does not allow setting fees at one level for a premium IOL and at a higher level if a femtosecond laser is used to perform the cataract surgery. This would amount to charging the patient for use of the laser for covered components of the procedure.

The final situation is blended vision/pseudophakic monovision. In some cases, the patient and the surgeon may agree that refractive benefits are gained by targeting one eye for distance and the other for near vision using conventional monofocal IOLs. If the patient has astigmatism as well, obtaining best results may require also treating the astigmatism (SCOCA). The patient may be charged for the additional refractive testing associated with these procedures. However, the patient may not be charged for the service of the femtosecond laser if it is used in this context.

Note the common theme: Patients may be charged out-of-pocket for refractive surgical procedures as well as the associated refractive testing and facility charges.

Q How should we document patient acceptance of financial responsibility for noncovered services?

A The practice must clearly identify the costs associated with noncovered refractive procedures and the patient must agree to be financially responsible. The patient should complete and sign an Advance Beneficiary Notice of Noncoverage or a Notice of Exclusion from Medicare Benefits before the surgery. For non-Medicare patients, a Notice of Exclusion from Health Plan Benefits serves the same purpose. OM

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