CODING & REIMBURSEMENT

The monovision option in cataract surgery

By Suzanne Corcoran

With the increased acceptance of cataract surgery with premium IOLs comes a renewed interest in monovision for many patients. Let’s brush up on coding for the procedure.

Q How does the surgeon evaluate a patient to determine if she or he is a suitable candidate for pseudophakic monovision?

A Pseudophakic monovision aims to provide excellent unaided vision following cataract surgery for presbyopic patients using conventional monofocal IOLs, with the surgeon aiming for emmetropia in the dominant eye and myopia in the nondominant eye.

While carefully selected and motivated patients achieve high levels of satisfaction, monovision is not appropriate for everyone. Each patient’s degree of spectacle independence depends on her or his tolerance for myopic defocus and interocular defocus.

Vision is not perfect either up close or far away as stereopsis is diminished. The patient may still require spectacles for some tasks.

To find the right patients, the surgeon administers a questionnaire designed to assess the patient’s vision requirements in the 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 the tests are refractive in nature.

The clinician administers these tests before the first operation, and may need to repeat some of them before the second procedure.

Suitability for pseudophakic monovision depends on matching patient expectations to tolerance for imbalance between the two eyes.

Q Does Medicare cover any of the preoperative testing?

A No. Medicare and most other third-party payers do not cover refractions, nor related refractive tests. (Medicare Claims Processing Manual, Chapter 21, §50.26.1).

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, the beneficiary should be advised in advance of her or his 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 Do we need to submit a claim for these tests?

A Medicare requires submitting a claim for non-covered services only if the patient requests it; otherwise, no. If you do submit a claim, refraction is reported as CPT code 92015. Modifier GY is used on Medicare claims to identify a service that is not a Medicare benefit.

Because a battery of related tests for pseudophakic monovision accompanies refraction in these patients, make a single charge for “refraction plus” and modifier 22 (unusual procedural services) appended to the CPT code. Modifier 22 signals an atypical service and also permits an atypical charge.

Q Are other charges associated with pseudophakic monovision?

A Sometimes. To achieve excellent unaided vision with pseudophakic monovision, the surgeon must minimize astigmatism. 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.