Ophthalmology and Optometry Coding Alert

CMS clarifies its P-C IOL policy, and grants NTIOL status to the AcrySof IQ

You already know that there's a new HCPCS code to report for the presbyopia- correcting function of an intraocular lens for a cataract patient. But questions have lingered on such issues as how much Medicare will let you charge, or what waivers the patient needs to sign. Here's what you need to know.

Medicare will pay for a regular intraocular lens to replace a natural lens removed during cataract surgery, says Raequell Duran, PC, president of Practice Solutions in Santa Barbara, Calif.--but a patient may instead request a presbyopia-correcting IOL, such as the Crystalens or ReSTOR lens.

Patients must pay that portion of the charge for the presbyopia-correcting IOL that exceeds the charge for insertion of a conventional IOL, according to CMS. HCPCS 2006 introduced V2788 (Presbyopia-correcting function of intraocular lens) to give ophthalmology coders a convenient way to bill the patient for the extra cost of a P-C IOL. (See "Report This New HCPCS Code for IOL Presbyopia Function" in the January 2006 Ophthalmology Coding Alert.)

In early June 2006, CMS updated the Frequently Asked Questions on its Web site to clarify portions of its P-C IOL policy. Some of the questions answered include:

Does the patient need to sign an ABN or waiver before the P-C IOL insertion? "No, there is no waiver for the beneficiary to sign," CMS answers. And because the P-C IOL is never covered by Medicare, there's no need for an advance beneficiary notice (ABN), says Kim Ford, coding manager for Campanella and Pearah Eye Care Associates in Sinking Spring, Pa. Instead, use an ABN for a service or item that Medicare normally covers but may not be medically necessary in a specific situation, CMS says.

However: There is another form you may consider giving the patient, Ford says. The Notice of Exclusion from Medicare Benefits (NEMB) "may be used to clarify that Medicare is not responsible for the additional costs associated with the beneficiary's choice to receive a presbyopia-correcting IOL and that the beneficiary understands that the responsibility for the additional costs are his," Medicare says.

You can download an NEMB at www.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf.

What's the correct coding for inserting a P-C IOL in the office, instead of a hospital or ASC? The same as it would be for a cataract surgery in which an ophthalmologist inserts a conventional IOL in any setting,  Medicare says. First, report V2630 (Anterior chamber intraocular lens) or V2632 (Posterior chamber intraocular lens) for the lens--Medicare will make the same payment for a P-C IOL as it would for a conventional lens. Report V2788 for "the noncovered charges associated with the procedure," CMS says.

Can an ASC charge the patient for the additional work required in inserting the P-C IOL (such as additional anesthesia services)? Yes, CMS says--the facility can charge the beneficiary for any additional costs associated with the insertion of the P-C IOL.

"The V2788 code is reported by hospitals, the ASC or the physician to report both the difference in cost of the  P-C IOL and any additional work and resources required for insertion, fitting, vision acuity testing and monitoring of the presbyopia-correcting IOL that exceed the work and resources attributable to insertion of a conventional IOL," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

"Of course, in the ASC the additional costs are limited to those associated with the surgical procedure because postoperative services such as fitting or visual acuity testing are not provided there," Medicare says.

Will CMS pay for a conventional IOL to replace a P-C IOL? Yes, if medically necessary, CMS says--for example, if the patient has complications with the P-C IOL. Even though the P-C IOL itself is noncovered, "Medicare payment may be made for covered services to treat a condition or complication that arises due to the use of a noncovered device or a noncovered device-related service."

Also, if the patient still needs post-op cataract eyewear following the insertion of a P-C IOL, Medicare will cover it: The rule "permits payment for one pair of eyeglasses or contact lenses following cataract surgery with insertion of an IOL."

You can read the questions and answers by going to http://questions.cms.hhs.gov and entering "IOL" in the "Search Term" field.

Add Alcon AcrySof to NTIOL List

ASCs using Alcon AcrySof IQ intraocular lenses can expect an extra $50 now that Medicare has approved the lenses as new-technology IOLs (NTIOL).

Starting May 19, 2006, ASCs can claim the extra payment with HCPCS code Q1003 (New technology intraocular lens category 3 as defined in Federal Register notice) submitted along with the facility's portion of the cataract extraction code. ASCs should append modifier SG (Ambulatory surgical center facility service) to the cataract code to differentiate it from the physician's services.

Payment to the ASC for the IOL itself is included in 6698x-SG. The adjusted payment for the AcrySof IOL (and for the only other allowable NTIOL, the Tecnis IOL) will be in effect until Feb. 27, 2011.

For more information on NTIOLs, see "Earn $50 More for Tecnis IOLs in an ASC With This New Code" in the June 2006 Ophthalmology Coding Alert.