Coding & Reimbursement

Premium IOL cases, co-management and coding

By Suzanne Corcoran

Co-management of premium IOL cataract cases continues to raise questions. Here are some you may have yourself:

Q May we co-manage when patients elect 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-impairing vision; and the other refractive — presbyopia or astigmatism. Treatment of the medical condition is covered, while the refractive treatment is non-covered and payable by the patient. These lenses are frequently referred to as “premium” IOLs.

Medicare permits co-management of these cases because its guidelines for co-management of postsurgical care do not depend on the type of IOL used. Follow existing co-management protocols for the covered portion of these procedures. Both the surgeon and the receiving physician are strongly encouraged (although not required) to obtain financial waivers in connection with providing non-covered services to Medicare beneficiaries electing a premium IOL. The waiver may take many forms, as long as it is clear.

Q May the non-covered services be co-managed?

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.

Q May the surgeon collect a single fee for the non-covered services and pay the referring doctor for his services?

A We don’t recommend it. To avoid any appearance of “payment for referrals” (also known as 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 co-managing physician; the patient makes out two checks — one each for the surgeon and co-managing physician).

Q Is the co-managing physician entitled to any part of the additional payment for the premium IOL?

A No. Charges and payments for the premium lens are handled at the HOPD or ASC. Neither the surgeon nor the co-managing physician is involved in this payment.

Q How is payment for the non-covered services divided for the physicians?

A Medicare’s co-management rules only provide instruction for covered services, so it is unwise to extrapolate Medicare’s 80/20 concept to the non-covered 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 co-managed care, the surgeon should reduce his charge by an amount that represents services he will not render. This way, co-management will not result in the patient paying much greater fees for the non-covered care.

Q What does the package of non-covered physician services include?

A The package of non-covered physician services is comprised of those additional tests, exams and procedures that are not related to the performance of traditional cataract surgery, or are defined as non-covered anyway. Each surgeon will determine what services to provide, but the list might include the following: refraction, contact lens trial fitting, wavefront aberrometry, corneal topography and pachymetry associated with refractive surgery, refractive keratoplasty and, in extraordinary cases, IOL exchange.