Ophthalmology and Optometry Coding Alert

Cataract surgeries are a routine part of most ophthalmologic surgery practices, and intraocular lens (IOL) insertion is a routine part of most cataract surgeries. But a new generation of multifocal IOLs is changing the routine -- both for the surgeon and the coder. To get reimbursement, you'll need to keep your HCPCS manual handy.

Background: After cataract surgery, in which the surgeon removes the patient's natural lens, Medicare will pay for the insertion of a new standard (monofocal) IOL. If the surgery takes place in the office, code V2632 (Posterior chamber intraocular lens) covers the cost of the standard IOL.

Exception: Code V2632 does not cover the additional cost of a multifocal IOL, which not only replaces the natural lens but also corrects refractive errors -- such as an astigmatism-correcting (A-C, also known as "toric") or presbyopia-correcting (P-C) IOL.

P-C IOLs go beyond the function of a standard IOL by correcting presbyopia, the inability to focus on near objects, explains Riva Lee Asbell, ophthalmic coding and reimbursement educator and principal of Riva Lee Asbell Associates in Ft. Lauderdale, Fla., who led the "Cataract/IOL & Corneal Transplant Coding" seminar at The Coding Institute's July conference. An A-C IOL corrects astigmatism, an irregular curvature of the cornea.

Turn to HCPCS Codes for Full Payment

Even though Medicare will not pay for the extra cost of an A-C or P-C IOL, it will allow you to bill the patient for the difference, using two HCPCS codes: A-C IOLs: Report V2787 (Astigmatism correcting function of intraocular lens). Medicare recognizes these as A-C IOLs:

• AcrySof Toric IOL (models SN60T3, SN60T4, SN60T5)

• AcrySof IQ Toric IOL (models SN6AT4, SN6AT5, SN6At6)

• Silicone 1P Toric IOL (models AA4203TF, AA4203TL).

P-C IOLs: Report V2788 (Presbyopia correcting function of intraocular lens). Medicare recognizes these P-C IOLs:

• Crystalens

• AcrySof ReSTOR

• ReZoom

• Tecnis Multifocal Acrylic Intraocular Lens

• Tecnis Silicone Intraocular Lens.

Key: Coders in ambulatory surgical centers (ASCs), hospital outpatient departments (HOPDs), and physician offices can report V2787 or V2788 for the extra IOL cost. However, ASC and HOPD coders should not report V2632. "The payment for the conventional lens portion ... continues to be bundled with the facility procedure payment for ASCs and HOPDs," explains Medicare in Transmittal 1430, released in February 2008. Only report V2632 for procedures performed in the ophthalmologist's office.

GY option: Reporting V2787 or V2788 to Medicare is optional, notes Asbell. The patient may ask you to do so in order to receive a denial that he can then show to a secondary payer to receive payment. In that case, append  modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non- Medicare insurers, is not a contract benefit) to the V code and have the patient sign Medicare's Notice of Exclusion From Medicare Benefits (NEMB) form.

NTIOL? Try Q1003

Don't confuse A-C and P-C IOLs with new technology IOLs (NTIOLs). NTIOLs are a different category of IOLs that reduce corneal spherical aberrations. Medicare recognizes them as having "specific clinical advantages and superiority over existing IOLs with regard to reduced risk of postoperative complication or trauma, accelerated postoperative recovery, reduced induced astigmatism, improved postoperative visual acuity, more stable postoperative vision, or other comparable clinical advantages."

ASC coders: In 2006, Medicare began reimbursing $50 extra for certain NTIOLs inserted in an ASC. Use HCPCS code Q1003 (New technology, intraocular lens, category 3 [reduced spherical aberration]) for this amount.

As the code descriptor indicates, Q1003 is only for NTIOLs defined by CMS as "category 3." These are:

• AcrySof IQ (model SN60WF)

• Acrysert Delivery System (model SN60WS)

• Affinity Collamer (models CQ2015A, CC4204A)

• Bausch & Lomb Akreos AO

• Elastimide (model AQ2015A)

• Hoya (model FY-60AD)

• Sofport (models LI61AO, LI61AOV)

• Tecnis (models Z9000, Z9001, Z9002, ZA9003, AR40xEM)

• Tecnis 1-Piece IOL (moel ZCB00).

Note: This category will expire on Feb. 26, 2011, says CMS. NTIOL categories 1 and 2 expired in 2005; HCPCS also has codes Q1004 (... category 4 ...) and Q1005 (... category 5 ...), which may apply to future applications of new technology, experts say.