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  • Coding and Billing for Premium Lenses

    One of the top cataract surgeons’ and practices’ coding and billing questions is how to code and bill for premium intraocular lenses (IOLs).

    The Centers for Medicare & Medicaid Services (CMS) has clearly defined what you can bill to them and what to bill patients when implanting a premium lens during cataract surgery.

    What Does CMS Cover?

    • Conventional IOL implanted during cataract surgery
    • Facility and physician services and supplies used to insert a conventional IOL during cataract surgery
    • 1 pair of prosthetic eyeglasses or contact lenses after each cataract surgery with IOL insertion. Durable medical equipment suppliers submit eyeglasses or contact lenses claims to their Medicare administrative contractors.

    What Does CMS Not Cover? 

    • Surgical correction, eyeglasses, or contact lenses to correct presbyopia or astigmatism, including the use of femtosecond laser (see laser question below)

    Medicare does not cover presbyopia-correcting IOLs, astigmatism-correcting IOLs and new technology IOLs. You can find a list of CMS-approved IOLs that you can bill to beneficiaries.

    What if a Patient Requests and You Recommend an IOL That’s Not Covered? 

    • Before surgery, inform the patient that Medicare doesn’t pay for insertion, adjustment or other subsequent IOL functionality treatments (physician and facility charges). 
    • If the patient still wants the IOL that’s not covered, make sure they understand the out-of-pocket cost. 
      • Medicare will pay the cost of the conventional lens.
      • The facility can bill the patient for the additional cost associated with the premium lenses.  

    Using a Laser to Remove a Lens 

    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. Medicare’s fee covers cataract surgery regardless of the surgical methods used, so don’t bill patients for the balance. 

    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 and limits the patient’s autonomy in making appropriately informed decisions for his or her eye care.

    Billing a Medicare Patient for Using a Laser in Cataract Surgery

    The Academy and the American Society of Cataract and Refractive Surgery (ASCRS) have published guidelines for billing Medicare beneficiaries when using a femtosecond laser. They outline two scenarios when it is appropriate to bill: 1) cases of refractive lens exchange; and 2) astigmatic keratotomy performed for refractive indications. The patient must be informed about and consent to additional out-of-pocket costs in advance.

    What About Other Payers? 

    The No. 1 rule of coding is to identify each payer’s coverage policy because all payers do not follow the same rules. This is especially true for CMS’ billing and coding rules for premium lenses. Commercial plans may have an allowable for the surgeon’s fee and/or for a premium lens cost. Medicare Advantage plans may require precertification stating noncoverage prior to billing the patient for premium IOL costs. 

    Further Resources

    Premium IOLs — A Legal and Ethical Guide to Billing Medicare Beneficiaries

    CMS Clarifies Femtosecond Medicare Billing

    Billing for Laser-Assisted Cataract Surgery

    Matthew Baugh, COT, MHA, OCS, OCSR About the author: Matthew Baugh, COT, MHA, OCS, OCSR, is a coding and reimbursement manager at the Academy.