Ophthalmology and Optometry Coding Alert

Medicare won't cover the full cost, but this expert advice will help you get the reimbursement you deserve

After cataract surgery, an ophthalmologist inserts a Crystalens intraocular lens to correct a Medicare patient's presbyopia. Can you code for the physician's services and supplies? The answer is yes--with these exceptions.

Presbyopia-correcting (P-C) IOLs can improve the quality of life for cataract patients who would otherwise need to rely on bifocals for near vision. Medicare typically covers the insertion of a conventional, clear IOL to replace the cataract-stricken lens that the ophthalmologist removes. In May, Medicare ruled that cataract patients who request a P-C IOL, such as the Crystalens or AcrySof RESTOR lenses, can have them--if they are willing to pay the extra cost.

The problem: Medicare only partially covers P-C IOLs, says Marco Ortiz, manager at Harvard Eye Associates in Laguna Hills, Calif. Although it does consider a conventional IOL medically necessary after cataract surgery, there is "no benefit category" for the presbyopia correction itself.

"A single presbyopia-correcting IOL essentially provides what is otherwise achieved by two separate items: an implantable conventional IOL (one that is not presbyopia-correcting), and eyeglasses or contact lenses," states CMS Ruling 05-01, released in May 2005. Medicare does cover one pair of eyeglasses or contact lenses for each patient following cataract surgery, but, "although presbyopia-correcting IOLs may serve the same function as eyeglasses or contact lenses furnished following cataract surgery, IOLs are neither eyeglasses nor contact lenses. Therefore, the presbyopia-correcting functionality of an IOL does not fall into the benefit category and is not covered."

This leaves coders with a unique dilemma: how to code for each portion of the IOL.

Report Cataract Codes for Covered Portion

Although Medicare has no immediate plans to establish new codes for the presbyopia-correcting (non-covered) portion of the P-C IOL, coding for the portion that Medicare does cover is fairly straightforward: Code for "a conventional IOL, regardless of whether a conventional or presbyopia-correcting IOL is inserted," directs an Aug. 5, 2005, CMS change request, "Instructions for Implementation of CMS Ruling 05-01: Presbyopia-Correcting Intraocular Lens."

For a cataract surgery with a P-C IOL insertion, report one of the following to Medicare:

• 66982--Extracapsular cataract removal with insertion of intraocular lens 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 capsulorrhexis) or performed on patients in the amblyogenic developmental stage

• 66983--Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure)

• 66984--Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification).

Warning: Although selecting, inserting and vision-acuity testing of a P-C IOL does involve more pre- and postoperative work by the ophthalmologist than a conventional IOL, don't be tempted to use that as a basis for reporting complex cataract surgery with 66982. "The insertion of a presbyopia-correcting accommodating device itself does not qualify to meet the level of work required to bill this code," says Part B carrier Blue Cross and Blue Shield of Kansas.

(For more information on when it's appropriate to code 66982, see "Simplify Complex Cataract Coding" in the October 2004 Ophthalmology Coding Alert.)

Resist Reporting Supplies Separately

Don't code separately for the IOL itself if the ophthalmologist inserted the IOL in a hospital or ASC, since Medicare includes the payment for the lens (generally $150) in the payment made to the facility for the entire procedure, says Kim Ford, coding manager for Campanella and Pearah Eye Care Associates in Sinking Spring, Pa.

"The beneficiary is responsible for payment of the portion of the facility charge which exceeds the charge for the ... non-presbyopia correcting IOL," says the Blue Cross and Blue Shield of Kansas LCD. The patient will have to pay the facility for the lens (typically over $800), minus the $150 that Medicare will cover.

Smart idea: "We charge the patient an upgrade fee for the lens," Ford says. "He doesn't pay any extra to the surgery center or to anyone else [for the lens]. We pay the facility out of our fee.

"However, if the procedure occurred in an office setting, Medicare directs you to use V2632 (Posterior chamber intraocular lens) for the IOL or P-C IOL.

Shun Unlisted-Procedure Code for Extra Services

The beneficiary is responsible for what Medicare doesn't cover, Ortiz says. CMS offers no clear advice on what code to use to bill the patient for these extra services, which can include testing like corneal topography or corneal pachymetry as well as added E/M time for pre- and postoperative care.

Experts warn: Don't be tempted to turn to the CPT code for unlisted procedure (66999, Unlisted procedure, anterior segment of eye). That code is for services assumed to be covered by the carrier for which no other CPT code is available. Since you know that the extra services are not covered, don't submit 66999 to Medicare or any other carrier for the portion of the service deemed to be noncovered.

For non-Medicare carriers, you can code these services with HCPCS code S9986 (Not medically necessary service [patient is aware that service not medically necessary]) linked to ICD-9 code 367.4 (Presbyopia). Append modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to the HCPCS code to indicate that you're not seeking payment from the carrier. The "S" code is not covered by Medicare statute and, therefore, should not be submitted to your Medicare carriers.

Best approach: Submit a claim to the carrier for the cataract surgery with 66982, 66983 or 66984. Collect the amount for the extra services directly from the patient--preferably before the surgery.

Note: To read the original ruling, go online to www.cms.hhs.gov/rulings. For the Medicare transmittal with additional coding guidance, visit www.cms.hhs.gov/manuals/pm_trans/R636CP.pdf.