Cataract surgery with implantation of an IOL is the single most commonly comanaged surgery within the Medicare program. Some of these procedures are performed using a premium IOL, which corrects presbyopia, astigmatism or both. I’ll address some of the issues associated with comanaging such procedures.

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

A. Cataract surgery that includes implantation of a presbyopia-correcting IOL (PC-IOL) or astigmatism-correcting IOL (toric IOL) treats more than one condition: medical — cataract impairing vision — and the other refractive — presbyopia, astigmatism or both. Treatment of the medical condition is covered, while the refractive treatment is noncovered and payable by the patient. These lenses are frequently 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 comanagement 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 either of its rulings^1,2 regarding premium IOLs, both eye-care providers — the surgeon and the comanaging eye-care provider — can participate in delivering the noncovered services that accompany the use of PC- or toric IOLs. Typically, a package of refractive services is identified rather than presented to the patient with an à la carte list of services.

Each party should obtain a financial waiver from the patient prior to surgery, indicating the patient’s willingness to assume financial responsibility for the noncovered 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 unrelated 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 to determine the refractive error
• Contact lens trial fitting to assess refractive error
• Wavefront aberrometry testing to assess refractive error
• Corneal topography associated with refractive surgery
• Corneal pachymetry associated with refractive surgery
• Routine eye care, wellness care or preventive care (i.e., to cope with refractive error)
• Refractive keratoplasty for the purpose of reducing dependence on eyeglasses or contact lenses (e.g., limbal relaxing incisions, LASIK, enhancements, and so on)
• IOL exchange in extraordinary cases

Q. How is the value of this package determined, and how is it divided between the physicians?

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. 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.

It’s important to remember that Medicare’s comanagement rules only provide instruction for covered services. Consequently, 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).

Q. May the surgeon collect a single fee for 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” (aka 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 eye-care provider — the patient makes out two checks (i.e., one check for the surgeon and one check for the comanaging physician).

Q. What about the additional payment for the premium IOL?

A. Charges and payments for the premium IOL are handled at the HOPD or ASC. Neither the surgeon nor the comanaging provider is involved in this payment.

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

A. Both the surgeon and the receiving eye-care provider are strongly encouraged (although not required) to obtain financial waivers in connection with providing noncovered services to Medicare beneficiaries receiving a PC-IOL or toric IOL.

An Advance Beneficiary Notice of Noncoverage (ABN) is required for services when Part B Medicare coverage is ambiguous or doubtful, and could be useful when a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA plans may have their own waiver forms or other processes. For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits is an alternative to an ABN. OM

REFERENCES

1. CMS Ruling 05-01. May 3, 2005. Accessed July 12, 2017.
2. CMS Ruling 1536-R. January 22, 2007. Accessed July 12, 2017.

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