Medicare Enters the Era Of Presbyopia Lenses

Donna McCune, CCS-P, COE
4/12/2006

Q: Does Medicare consider presbyopia-correcting IOLs to be new technology IOLs?

A:
No. None of the three manufacturers applied for new technology (NTIOL) status for their presbyopia-correcting IOLs. The May 3, 2005 Medicare Ruling defines three lenses, Crystalens (Eyeonics), the AcrySof ReSTOR (Alcon) and the Re­Zoom (Advanced Med­ical Optics), as presbyopia-correcting IOLs and al­lows beneficiaries to upgrade from a conventional IOL to a presbyopia-correcting IOL. The patient pays additional charges beyond those associated with standard cataract surgery. This approach differs from NTIOL reimbursement, which provides an additional $50 to an ambulatory surgery center when a NTIOL is implanted.




Q: Is charging Medicare patients for extra services and supplies associated only with presbyopia-correcting IOLs considered "balanced billing"?

A:
No. Billing patients for non­covered services and supplies has always been permitted by Med­icare and is not considered bal­ance bil­ling. Billing a pa­tient for the disallowed amount of a co­vered service when the pro­vider accepts as­signment of benefits is balance bil­ling. The pres­byo­pia-cor­recting IOL Med­icare ruling clearly distinguishes be­tween covered and non­covered items and services as­so­ciated with these IOLs. There is no change in Med­icare coverage of medically necessary cataract surgery and the corresponding payments. But the surgeon's and facility's charges for additional items and services to correct pres­byopia are not covered and are the pa­tient's responsibility. This concept is known as patient-shared billing, not balance billing. Patient-shared billing is national Med­­i­care policy and cannot be over­turned by local Med­icare carriers.

Q: Has Medicare assigned any new codes to describe the presbyopia-correcting IOL?

A: As of Jan. 1, 2006, HCPCS code V2788 describes the presbyopia-cor­rec­ting function of the IOL. Plac­ing this code on the Medicare claim form for the hos­pital or ASC is optional (and recommended).

Q: Do these claims require special modifiers or codes to describe the presbyopia-correcting IOL?

A: No. CMS Transmittal 636 dated Aug. 5, 2005 provides instructions for implementation of CMS Ruling No. 05-01, Pres­byopia-Cor­recting Intraocular Lens. It states, "No new codes are being es­tablished at this time to identify a presbyopia-correcting IOL or procedures and services related to a presbyopia-correcting IOL." (A code for the presbyopia-correcting function of the IOL was later re­leased, and effective Jan. 1, 2006.) No benefit category for coverage of these services and supplies exists; therefore, Medicare does not require reporting of these items or services.

Q: Does Medicare cover tests and procedures to treat astigmatism at the time of cataract surgery?

A: No. Diagnostic tests, such as corneal topography, and procedures, such as limbal relaxing incisions, to treat astigmatism and minimize dependence on eye­glasses are considered refractive services and are usually not covered by Medicare except for extraordinary situations. The patient is financially responsible for these extra charges. Medicare position on these services does not depend on the type of IOL that is implanted.

In addition, the May 3, 2005 Medicare ruling did not change patients' eligibility to receive a covered pair of post-cataract eyeglasses if they do not receive the optimal benefit of the IOL at all distances.

Q: If the patient develops posterior capsular opacity following implantation of a presbyopia-correcting IOL, will Medicare cover a YAG laser capsulotomy?

A: As a medically necessary procedure, YAG capsulotomy is covered. Coverage criteria include re­duced visual acuity (check your local carrier policy for specifics), and a complaint from the patient.

Q: May a surgeon who purchases an IOL from the manufacturer sell it to the ASC or hospital outpatient department?

A: It's illegal for a surgeon to re­sell the presbyopia-correcting IOL to the HOPD or ASC where he performs the cat­aract surgery if he gains from the sale in any way. The sur­geon may resell the lens to the HOPD or ASC where he performs the cat­aract surgery if there is no prof­it on the sale. The surgeon may not claim re­im­bursement with the health insurance plan for the IOL if the surgery is performed in a HOPD or ASC. The HOPD or ASC may not file a claim for re­­imbursement if it did not purchase the presbyopia-correcting IOL.

Q: Is co-management of cataract surgery using a presbyopia-correcting IOL permitted?

A: Medicare's guidelines for co-man­agement of post-sur­gical care do not depend on the type of IOL used. Follow ex­ist­ing co-man­agement prot­o­cols for the covered portion of these procedures. Ad­di­tion­ally, while Med­icare did not address the issue in either the May 2005 or August 2005 regulations, both physicians can participate in providing the non-covered services that accompany the use of these lenses.

Q: How is the value of this package divided be­tween co-managing providers?

A: Medicare's co-management rules only provide instruction for covered services, not non-covered services. Con­se­quently, 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 package charge by an amount that represents services he will not render.

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

A: This approach is fraught with trouble and not recommended. In order to avoid any ap­pearance of "payment for referrals" (i.e., kickback), each provider should charge and collect only 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 (i.e., one check for the surgeon, and the other check for the receiving physician).

 

Ms. McCune is vice pres­ident of the Cor­coran Con­sult­ing Group. Con­tact her at DMcCune@corcoranccg.com.