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  • Savvy Coder

    Increasing Revenues in a Climate of Payment Change: Out-of-Pocket Charges

    By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

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    An administrator asks, “One sur­geon in our practice performs 350 cataract extractions with IOL [intraocular lens] and 30 com­plex cataract surgeries per year: With the payment cuts to these procedures in 2020, what can we do to offset the payment cuts in our office?”

    Good question! Boosting revenues should involve an assessment of all practice activities, including a review of coding and billing practices. Here are a few pointers to get you started.

    Out-of-Pocket Charges

    Whether a patient’s insurance is federal or commercial, payers don’t cover every exam, test, and surgery. The list of when you can, and should, get paid by the patient includes, but is not limited to, the following goods and services.

    Refraction. There has been a separate CPT code for refraction since 1992, but many practices still do not collect the refraction charge when it is not covered by Medicare or the vision plan.

    Cosmetic surgery. You may be able to charge the patient for skin tag remov­al, Botox (botulinum toxin) for wrin­kles, blepharoplasty, and other oculo­facial procedures if they don’t meet the payer’s functional criteria. Check your payer’s Local Coverage Determination at

    Fees associated with a “premium” IOL. Patients who qualify for either a toric or presbyopic IOL may be charged certain out-of-pocket expenses associ­ated with these premium lenses. (For more details, see the October 2018 Savvy Coder.)

    Contact lenses. Charge patients for refractive and/or bandage contact lenses when not covered by insurance.

    Optical. While postcataract glasses are a covered Medicare Part B benefit, upgrades are not. For commercial in­surance: Unless the patient has elected for optical as part of their coverage, most costs for frames, lenses, and upgrades are the patient’s payment responsibility.

    Dry eye. Some tear testing for dry eye can be charged to the patient; see the fact sheet section at

    Correction of the patient’s natural astigmatism. At the time of cataract surgery with a standard IOL, patients may elect to pay to have their natural astigmatism (not induced by surgery or trauma) corrected by laser or blade.

    Refractive surgery. Typically, insur­ance doesn’t cover procedures such as LASIK, photorefractive keratectomy (PRK), conductive keratoplasty, corneal inlay procedures, implant or lenticule procedures, or scleral procedures for the correction of refractive error or presbyopia.

    Cross-linking (CXL). Insurance doesn’t always cover CXL procedures for keratoconus.

    Clear lens exchange. High myopes who do not have a cataract may elect to have their natural lens removed, but this is not a covered benefit by insurance. All costs—including for the facility, the anesthesiologist, and the surgeon—will be paid directly by the patient.

    Category III CPT codes. Category III CPT codes document use of new or emerging technology. Many of them do not have a payer allowable and can be charged to the patient.

    Boutique services. You may be able to bill the patient for additional testing services or lid hygiene associated with eyelash extensions.

    ABNs. If an exam, test, or surgery is not a covered benefit, an Advance Ben­eficiary Notice (ABN) is not required and a claim should not be submitted to Medicare Part B. However, if the patient insists that you submit a claim, append modifier –GY.

    Common Coding Errors to Avoid

    Practices that correct the errors listed below will see an immediate impact on their financial bottom line. Practices that don’t will continue to perpetuate the same coding submission errors over and over.

    Reporting the referring physician on the CMS 1500 form. Listing the referring physician, rather than the ordering or supervising physician from your practice, may cause problems. For example, you might not know the full name of the referring physician, and a missing middle initial is enough to have a claim denied. You also might run into problems when referring physicians haven’t kept their PECOS information up to date. (PECOS stands for Provider Enrollment, Chain and Ownership System.)

    Linking the wrong ICD-10 code to the CPT code. When the remittance advice states that an exam, test, or surgery isn’t medically necessary, it really means that either the diagnosis isn’t a covered benefit for the CPT code or you’ve linked the wrong ICD-10 code to the CPT code that you are billing (e.g., linking a cataract diagnosis to a visual field service).

    Wrong or missing modifier. For tips on modifiers, visit to view the Modifier Mastery in Minutes series, which starts this month.

    Failure to preauthorize is a guarantee of nonpayment. If possible, preau­thorize while the patient is present. See the AAOE’s preauthorization checklist at

    Misunderstanding the SNF rules. While a patient is in a skilled nursing fa­cility (SNF), Medicare Part B won’t pay for postcataract glasses, any injectable drug (such as anti-VEGF medications), or the technical component of any del­egated test. In addition, there is no guarantee that payment for any elective minor or major surgery will be a covered benefit.

    Failure to append modifier –GW for hospice patients. To show that the exam or test you perform is unrelated to the hospice care the patient is receiving, append modifier –GW to the claim. There is no guarantee that any elective minor or major surgery is a covered benefit.

    Failing an audit takes a significant toll. To see who is auditing and what areas they are targeting, visit For recent trends, see the “Why Your Ophthalmology Colleagues Were in the Auditors’ Crosshairs” (Savvy Coder, December 2019). If you receive a request for records and you’d like to communicate with Academy staff, please email the specifics to

    Par Versus Non-Par Versus Opting Out

    Has the reduction in cataract fees diminished your enthusiasm for Medicare? Your options include: 1) continue to be a participating physician (“par”); 2) be a non-participating physician (“non-par”); or 3) opt out of Medicare.

    The AAOE has posted more information on these three options at

    Want More Tips?

    This month’s Savvy Coder is based on an AAO 2019 session presented by Robert Wiggins, MD, MHA, Julia Lee, JD, Ravi D. Goel, MD, and Ms. Vicchrilli. It was full of easy-to-imple­ment tips for boosting revenue and cutting costs, many of which have now been posted online. 

    Want more ideas for improving your bottom line? You can learn about lean management at