Ophthalmology and Optometry Coding Alert

Medicare provides a code for the supply, but the beneficiary must still pay

If your ophthalmologist performs cataract surgery in the office, some of his patients have probably requested a new presbyopia-correcting IOL to replace their natural lenses after surgery. A code already exists for the supply of a regular IOL--V2632--but that code doesn't include the presbyopia-correcting function of the Crystalens or RESTOR lens.

That will change starting Jan. 1. HCPCS 2006 includes a new supply code, V2788 (Presbyopia correcting function of intraocular lens), for the extra cost of a P-C IOL--but your patients will still be liable for the difference in price between the two lenses.

When an ophthalmologist in your practice inserts a presbyopia-correcting intraocular lens after cataract surgery in the office, you should still report the HCPCS code for a regular IOL, V2632(Posterior chamber intraocular lens), for the supply. And for services performed on Jan. 1 or later, you should also report  V2788 when appropriate.

Background: Medicare will pay for a beneficiary to receive a new standard IOL (or one new pair of glasses) after each cataract surgery in which the ophthalmologist removes a natural IOL.

A 2005 ruling by CMS clarified its policy, stating that a beneficiary may request insertion of a presbyopia-correcting IOL instead of a conventional IOL.

The ruling also affirmed that the beneficiary is responsible for payment of that portion of the charge for the presbyopia-correcting IOL that exceeds the charge for insertion of a conventional IOL.

The new HCPCS code does not mean that Medicare will start paying for the presbyopia-correcting function. HCPCS 2006 gives V2788 a coverage code of "S," which indicates that it is non-covered by Medicare statute. The beneficiary will still be responsible for the extra payment.

However, V2788 provides ophthalmology coders with a convenient way to bill the patient for the price difference between a normal IOL and a presbyopia-correcting one.

Example: After cataract surgery, a patient receives a presbyopia-correcting IOL. The cost of a normal IOL is $100, and a P-C IOL costs $150. Code the supplies as:

• V2632 x 1, $100
• V2788-GY x 1, $50.

Append modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to show that you are not seeking payment from Medicare, and to speed the denial process.
 Warning: Don't code for the supplies at all if the ophthalmologist is performing the surgery in a hospital or ASC. Medicare's ruling maintains that payment for the lens is included in the payment made to the facility for the entire procedure.

Note: For more information on coding for P-C IOL services and supplies, see "Focus on Cataract Codes for Airtight Presbyopia-Correcting IOL Coding" in the October 2005 Ophthalmology Coding Alert.