Cataract surgery is one of the most common surgeries performed in the United States. Due to its frequency, it is often an audit target for all payer types. The Centers for Medicare and Medicaid Services (CMS) and its associated Medicare Administrative Contractors (MACs) have published guidelines clearly outlining facility and physician billing and coding requirements for cataract surgeries in documents called local coverage determinations (LCDs) and local coverage articles (LCAs). Many private payers also have published cataract surgery guidelines. While the removal of the cataract is covered by most payers, coverage for the type of intraocular lens (IOL) that is implanted varies by the payer.

CMS covers the implantation of a conventional IOL during cataract surgery, reimbursing for the facility and physician services, the IOL, and certain supplies that are necessary for the surgery.¹ CMS defines a conventional IOL as “a small, lightweight, clear disk(s) that replaces the distance focusing power of the eye’s natural crystalline lens. When a conventional IOL is inserted subsequent to removal of a cataract, eyeglasses or contact lenses are usually required to provide near or intermediate vision.”²

Medicare considers certain IOLs “nonconventional.” These are often called premium lenses, because they enable the cataract surgeon to treat vision problems, such as astigmatism, myopia, or hyperopia, in addition to the cataract, thereby reducing or eliminating the need for eyeglasses or contacts. CMS recognizes three main classes of nonconventional lenses: presbyopia-correcting IOLs (PC IOLs), astigmatism-correcting IOLs (AC IOLs), and lenses that correct both presbyopia and astigmatism (PC/AC IOLs). Each year, CMS updates its list of nonconventional IOLs.³ Following are answers to some commonly asked questions about the proper way to code and bill CMS for cataract surgery when a premium lens is used, so that audits don’t turn up any problems.

Q. WHAT CODES SHOULD BE USED FOR CATARACT SURGERY THAT INVOLVES IMPLANTATION OF A PREMIUM LENS?

A. According to CMS, the ASC should bill for the appropriate cataract removal and lens insertion procedure performed.¹ The following codes are approved for cataract removal with PC or AC IOL billing:

• 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique, (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic development stage; without endoscopic cyclophotocoagulation
• 66983 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1-stage procedure)
• 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure) manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation
• 66987 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation
• 66988 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation

Q. WHAT LENS CODE SHOULD BE USED IN THESE CASES?

A. In addition to the appropriate procedure code, the facility must report the appropriate HCPCS code, even though Medicare does not cover the full cost of the premium lenses.

• Bill V2632 to report conventional posterior chamber intraocular lens.
• Bill V2787 to report the noncovered AC IOL functionality charges of the inserted intraocular lens.
• Bill V2788 to report the noncovered PC IOL charges of the inserted intraocular lens.

Q. WHAT CAN ASCS CHARGE THE MEDICARE PATIENT WHEN A PREMIUM LENS IS IMPLANTED?

A. Reimbursement to the ASC from Medicare for cataract surgery removal and insertion of an IOL includes a packaged remittance for the procedure and a conventional lens. ASCs may bill the patient for the dollar difference between the $150 that Medicare pays for the conventional lens (included in the facility fee) and the cost of the premium IOL, plus a small handling fee. ASCs may also charge a fee for use of Alcon’s Optiwave Refractive Analysis (ORA) System’s WaveFront intraoperative aberrometry feature when premium IOLs are implanted.⁴

Q. WHAT ABOUT WHEN A LASER IS USED TO HELP REMOVE THE LENS?

A. If a surgeon uses a femtosecond laser to help remove the lens during cataract surgery when a conventional IOL is implanted, neither the surgeon nor the facility may obtain reimbursement from either Medicare or the Medicare beneficiary over and above the Medicare-allowable amount.⁵ Medicare’s fee covers cataract surgery regardless of the surgical methods used, so patients must not be balance-billed. Patients also should not be led to believe there are additional charges for the use of a laser to help remove the cataract. This misrepresents both the services to be performed and the charges for those services, limiting the patient’s autonomy in making appropriately informed decisions for his or her eye care.

Q. WHEN IS IT APPROPRIATE TO BILL THE MEDICARE PATIENT FOR THE USE OF A LASER WHEN USED DURING CATARACT SURGERY?

A. The American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) have published guidelines for billing Medicare beneficiaries when using the femtosecond laser.⁶ These guidelines outline two scenarios when it is appropriate to bill: in cases of refractive lens exchange or astigmatic keratotomy performed for refractive indications. The patient must be informed about, and consent to the additional out-of-pocket costs in advance.

Q. WHAT ABOUT COMMERCIAL PAYERS?

A. The number one rule of coding is to identify the payer. Why? Because all payers do not follow the same rules. CMS IOL coverage rules do not apply to all payers. Commercial plans may have an allowable for the surgeon’s fee and/or for the cost of a premium lens. Additionally, Medicare Advantage plans may require precertification stating noncoverage prior to billing the patient for premium IOL costs. It is imperative to verify the coverage policy for each payer. OASC

REFERENCES

1. Centers for Medicare and Medicaid Services. “MLN Fact Sheet: Medicare Vision Services.” August 2021. Accessed December 2, 2022. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/VisionServices_FactSheet_ICN907165.pdf
2. Centers for Medicare and Medicaid Services, “Pub 100-04 Medicare Claims Processing. November 28, 2022. Accessed December 2, 2022. https://www.cms.gov/files/document/r11721cp.pdf
3. Centers for Medicare and Medicaid Services. “CMS Recognized Presbyopia-Correcting (PC) IOLs and Astigmatism-Correcting (AC) IOLs.” September 2022. Accessed December 2, 2022. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/PCIOL-ACIOL.pdf
4. Vicchrilli S, Glasser DB, McNett C, Repka MX. Premium IOLs—A Legal and Ethical Guide to Billing Medicare Beneficiaries. Eyenet. 2018;36(10):79-80. Accessed December 2, 2022. https://www.aao.org/eyenet/article/premium-iols-a-legal-and-ethical-guide
5. Centers for Medicare and Medicaid Services. “Laser-Assisted Cataract Surgery and CMS Rulings 05-01 and 1536-R.” November 16, 2012. Accessed December 2, 2022. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/Downloads/CMS-PC-AC-IOL-laser-guidance.pdf
6. American Society of Cataract and Refractive Surgeons. “Femtosecond Laser Billing.” Accessed December 2, 2022. https://ascrs.org/advocacy/regulatory/guidelines/femtosecond-laser-billing

Matthew Baugh, MHA, COT, OCS, OCSR, is a coding and reimbursement manager for the American Academy of Ophthalmology in San Francisco. Reach him at mbaugh@aao.org.