Ophthalmology and Optometry Coding Alert

Also: Expecting extra pay for new-technology intraocular lenses? Read this first.

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, assign HCPCS code V2632 (Posterior chamber intraocular lens) to cover 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. An A-C IOL corrects astigmatism, an irregular curvature of the cornea.

Turn to HCPCS Codes for Full Payment

"Patients may be offered the non-covered lens and physicians are advised to counsel the patient that the cost will be their responsibility," explains Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Hospital Ambulatory and Network Oversight at the Mount Sinai Medical Center Compliance Department in New York City. Collect the cost up-front or have the patient sign a financial responsibility agreement, she advises. Even though Medicare will not pay for the extra cost of an A-C or P-C IOL, it is appropriate 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
• AcrySof IQ Toric IOL
• Silicone 1P Toric IOL.

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

• AcrySof ReSTOR
• AcrySof IQ ReSTOR
• Crystalens
• ReZoom
• Tecnis Multifocal Acrylic Intraocular Lens
• Tecnis Multifocal 1-Piece Intraocular Lens
• Tecnis Silicone Intraocular Lens.

Note: For complete manufacturer and model number information, download the current list of Medicare-approved A-C and P-C IOLs at www.cms.gov/ASCPayment/08_NTIOLs.asp.

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. 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.

No More New Technology IOL Reimbursement

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: A few years ago, Medicare began reimbursing $50 extra for certain NTIOLs inserted in an ASC. Coders reported HCPCS code Q1003 (New technology, intraocular lens, category 3 [reduced spherical aberration]) when their ophthalmic surgeons inserted NTIOLs such as the AcrySof IQ, the Bausch & Lomb Akreos AO, and the Tecnis 1-Piece IOL. However, that new technology category expired a year ago, on Feb. 26, 2011, and Medicare has approved no new class of NTIOLs to take its place. Therefore, the code does not appear in the 2012 HCPCS manual, and coders should not report it.

Note: 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.