An update on presbyopia-correcting IOLs

Medicare ruling says beneficiaries to be charged for non-covered portions of the surgical procedure

CMS (Centers for Medicare and Medicaid Services) has issued four important documents in reference to the precedent-breaking ruling that allowed a beneficiary to be charged for a non-covered portion of a surgical procedure while maintaining coverage for a portion of the same procedure.
The four documents that CMS has issued to date are:
• CMS Ruling No. 05-01, issued May 3, 2005
• Transmittal 636/Change Request 3927, dated August 5, 2005, for insertion in the Medicare Claims Processing Manual
• Transmittal 782/Change Request 4184, dated December 30, 2005, for insertion in the Medicare Claims Processing Manual
• Frequently Asked Questions, dated March 8, 2006.1 http://questions.cms.hhs.gov
Further clarifications are expected.
This review outlines some of the more important highlights emanating from these documents concerning presbyopia-correcting intraocular lenses (P-C IOLs).

Pre-op Assessment/Documentation

Chart documentation
Notification of costs. It is mandated by CMS that the beneficiary request the P-C IOL and be made aware of the charges in writing. This is best accomplished by outlining the costs in a document that is signed by the patient and using an NEMB (Notice of Exclusion from Medicare Benefits) that clarifies that Medicare is not responsible for the additional costs associated with use of this type of lens and that the patient is responsible. This notification should be given in writing by both the physician and the facility.
NEMB versus ABN. The CMS documents recommend that an NEMB rather than an Advanced Beneficiary Notice (ABN) be used because the portion of the charges excluded from coverage are based on statutory exclusion rather than one of medical necessity (charges that are not medically reasonable and necessary).
Activities of daily living documentation. It is essential that problems with activities of daily living are documented in the chart in addition to the physician's assessment that the patient needs cataract surgery.
Audit environment. Audits currently are being conducted by the OIG (Office of the Inspector General) on global surgery Medicare claims specifically related to cataract surgery (CPT 66984). They are assessing pertinent medical record documentation to determine whether the services billed were reasonable and allowable and that all other requirements for Medicare coverage were met.

Surgical procedure coverage

The list of covered surgical procedure codes was expanded to include the following Current Procedural Terminology (CPT) codes: 66982, 66983, 66984, 66985, 66986.
CPT code descriptions:

• 66982. Extracapsular cataract removal with insertion of IOL prosthesis (one-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 capsulorhexis) or performed on patients in the amblyogenic developmental stage.
• 66983. Intracapsular cataract extraction with insertion of IOL prosthesis (one-stage procedure).
• 66984. Extracapsular cataract removal with insertion of IOL prosthesis (one-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification).
• 66985. Insertion of IOL prosthesis (secondary implant), not associated with concurrent cataract removal.
• 66986. Exchange of IOL.

The surgery

HCPCS Code V2788. This code was issued effective January 1, 2006, so that physicians and facilities had a code to report on claims that might be submitted for charges related to the P-C IOL. Its use is optional, not mandatory.
Physician charges. Physicians are permitted to charge the patient a “presbyopia-correcting IOL package” fee that may include “physician work and resources required for insertion, fitting, and vision acuity testing of the presbyopia-correcting IOL compared to insertion of a conventional IOL.” The physician is free to include any other non-covered services in the “package” such as post-op enhancement by LASIK.
Physician purchase of P-C IOL. Physicians are prohibited from billing Medicare for these lenses when the surgery takes place in a hospital or an Ambulatory Surgery Center (ASC). There are specific instructions when a P-C IOL is inserted in a physician's office.
Facility charges. The original ruling states that “the beneficiary is responsible for payment of that portion of the facility charge that exceeds the facility charge for insertion of a conventional IOL following cataract surgery. In addition, the beneficiary is responsible for the payment of facility charges for resources required for fitting and vision-acuity testing of a presbyopia-correcting IOL that exceeds the facility charges for resources furnished for a conventional IOL following cataract surgery.”
This question was asked in the CMS Q&A: “… does that mean the ASC can also charge the patient a 'presbyopic package' that includes not only the difference in the presbyopia-correcting IOL and the standard IOL, but also an additional amount for work required in inserting the presbyopia-correcting IOL, additional anesthesia services, etc.?”
The response: “The ASC may charge the beneficiary for any additional costs associated with insertion of the presbyopia-correcting IOL. Of course, in the ASC the additional costs are limited to those associated with the surgical procedure because post-operative services such as fitting of visual-acuity testing are not provided there.”
In answer to a related question-whether there are “standard and customary” charges” for a non-covered service-the following response was issued: “Medicare has no authority to place any limit on the amount that providers may charge for any additional costs associated with the insertion of the presbyopia-correcting IOLs. We will not determine 'standard and customary' charges for a non-covered service.”
THE IOL
Coverage of P-C IOLs. The following P-C IOLs are permitted to be used:
• CrystaLens , (eyeonics Aliso Viejo, Calif.)
• AcrySof RESTOR (Alcon Laboratories, Forth Worth, Texas)
• ReZoom (Advanced Medical Optics, Santa Ana, Calif.)
Presently, there is no announced mechanism for obtaining approval for additional P-C IOLs.

Post-op care

Global period. For Medicare, the 90 global period remains. Additional procedures performed during the global period will be paid with use of an appropriate modifier.
Extra procedures may be bundled into the “P-C IOL package” such as LASIK.
Additional procedures. Medicare will pay for procedures related to the original surgery such as complications that result in exchange or removal of the IOL, evacuation of hyphema, or repositioning of an IOL requiring an incision. The procedure must be performed in an operating room as defined by Medicare.
Eye codes. Transmittal 801 specifies that hospitals and physicians shall bill the eye codes for evaluation and management services associated with the services following cataract extraction surgery. Further clarification to include the E/M codes is hopefully on the horizon.
Glasses after cataract surgery. Medicare will pay for one pair of contact lenses or eyeglasses after the insertion of a P-C IOL-the same as when a non-presbyopia-correcting IOL is used.
CPT codes copyrighted 2006 American Medical Association.

ABOUT THE AUTHOR

Riva Lee Asbell, an ophthalmic reimbursement consultant, is the principal of Riva Lee Asbell Associates, Philadelphia. Contact her at 215-629-9221 or rivalee@aol.com.