CODING & COMPLIANCE

Laser-assisted Surgery & Medicare Compliance

BY RIVA LEE ASBELL

With the constant barrage of information that one needs to keep up with in ophthalmology, 3 years is a very long time. And it has been 3 years since the AAO/ASCRS and the CMS issued their guidelines (January 2012 and November 2012 respectively) regarding when patients may be billed for surgical services — or portions of surgical services — that involve the use of laser-assisted ophthalmic surgery.^1,2 Below I will clarify issues surrounding femtosecond laser billing such as the Q&A below — which offers an incorrect listserv answer.

Q. Have any practices used the femtosecond laser for performing cataract surgery? Can you bill this to insurance or does it go with the 66984?

A. This is elective for patients, so they must pay out of pocket. Medicare does not pay for this service.

There are specific guidelines when billing patients for the premium services that aren’t covered by Medicare. In order to correct misconceptions, this review addresses the three main areas in which laser-assisted ophthalmic surgery is currently being utilized: cataract, refractive and cornea surgery.

LASER-ASSISTED CATARACT SURGERY

Message from CMS: Misleading advertising prompted CMS Guidance.

“We are providing this guidance because of a recent press release from an ophthalmology practice that described use of bladeless, computer-controlled laser surgery for cataract removal. The press release may imply a different Medicare policy regarding non-covered services that may be charged to the beneficiary if the cataract surgery is performed using a bladeless, computer-controlled laser. The press release states:

‘While traditional cataract surgery is fully covered by most private medical insurance and Medicare, bladeless cataract surgery requires patients to pay out-of-pocket for the portion of the procedure that insurance does not cover.’

Neither the physician nor the ASC may bill patients for any portion of cataract surgery since all types of cataract surgery, when medically necessary, are a covered benefit of the Medicare program. Early on there was a good deal of confusion about this, so the AAO and ASCRS issued joint guidelines to address the issues. These guidelines addressed when patients could be billed for the refractive (non-covered) portion of surgeries and we will examine them in detail. After these guidelines were issued, CMS issued a statement clarifying prior rulings and this was followed by minor revisions in the AAO/ASCRS Guidelines.

Message from CMS: Neither the surgeon nor the ASC is permitted to bill the patient for cataract surgery no matter what technique is used.

“Medicare coverage and payment for cataract surgery is the same irrespective of whether the surgery is performed using conventional surgical techniques or a bladeless, compact controlled laser. Under either method, Medicare will cover and pay for the cataract removal and insertion of a conventional intraocular lens. If the bladeless, computer-controlled laser cataract surgery includes implantation of a PC-IOL [Medicare’s term for presbyopia correcting intraocular lens] or AC-IOL [Medicare’s term for astigmatism correcting intraocular lens], only charges for those non-covered services specified above may be charged to the beneficiary.”

In summary, at this time, as far as Medicare is concerned, the patient can never be charged extra for any technique used in conjunction with any form of medically necessary cataract surgery by either the surgeon or the facility.

The global surgery package for Medicare includes incisions and closure and thus laser-assisted cataract surgery is not paid by Medicare and cannot be billed to the patient.

CATARACT SURGERY COMBINED WITH REFRACTIVE SURGERY (SAME SESSION)

The aforementioned guidelines issued by AAO and ASCRS for both physicians and facilities explicitly delineates when a patient may be billed. Essentially, a patient may only be billed for services that aren’t covered by Medicare and, in this context, are refractive in nature.

Refractive Lens Exchange.

• The surgeon and the facility may bill the patient for refractive lens exchange and for an astigmatic keratotomy (AK) performed in conjunction with medically necessary cataract surgery.

• The surgeon and the facility may charge an additional fee to the patient for the use of a refractive intraocular lens (presbyopia correcting or astigmatism correcting).

• Since this is a totally non-covered procedure, an additional fee to use the femtosecond laser for any lens removal steps may be charged by the physician and/or facility. It’s critical to have the proper chart documentation including a proper informed consent.

Medically Necessary Cataract Extraction with a Conventional IOL or Premium IOL and No Astigmatic Keratotomy.

• In either instance, billing the patient if laser-assisted surgery is used is prohibited. The patient may only be billed within Medicare’s parameters for the premium IOL package.

Medically Necessary Cataract Surgery Plus Astigmatic Keratotomy Performed for Refractive Indications.

• If laser-assisted cataract surgery is performed as well as laser-assisted AK, the patient may be charged only for the laser-assisted AK portion. This should be well documented in advance of the surgery.

Note that Medicare does cover correction of astigmatism alone if it resulted from previous surgery or trauma. However, you may not bill the patient additionally for the use of laser-assisted surgery for these medically necessary procedures.

LASER-ASSISTED CORNEA SURGERY

The codes below were developed for the laser incisions based on the incisions being performed in the laser suite and the keratoplasty procedures being performed in the operating room of the hospital or ASC. They are add-on codes (noted by the + sign before the code) signifying the codes cannot be used independently. Since these are Category III codes, Medicare reimbursement as well as the coverage itself is at the discretion of CMS or the MAC (Medicare Administrative Contractor). The codes are packaged on the national fee schedule with the surgery fee in 2015 and therefore cannot be billed to the patient. Neither the surgeon nor the ASC will be reimbursed.

CPT Listings for Category III codes:

The above codes are for keratoplasty only and not cataract surgery. ■

References