Ophthalmology and Optometry Coding Alert

Your physician -- and patients -- can now choose which IOL is the best option

Good news: On Jan. 22, CMS published Ruling  No. CMS-1536-R, which states that Medicare beneficiaries can now choose implantation of an intraocular lens (IOL) that corrects pre-existing astigmatism at the time of cataract surgery.

Background: Medicare covers conventional IOLs when the ophthalmologist performs the insertion following cataract surgery, the ruling says. The document goes on to explain that in the past "... except following cataract surgery with insertion of an IOL, Medicare does not cover eyeglasses or contact lenses. And Medicare does not cover the surgical correction or cylindrical lenses of eyeglasses or contact lenses that may be required to compensate for the imperfect curvature of the cornea."

Problem: Ophthalmologists often insert IOLs to correct astigmatism after cataract surgery, but Medicare doesn't consider an IOL used for its astigmatism-correcting function a coverable service. Medicare also won't pay you for any ophthalmologic services associated with this type of IOL insertion, such as eye examinations your ophthalmologist performs to determine the refractive state of the eyes following the IOL insertion.

What it means: This new CMS guideline is similar to a prior CMS ruling for presbyopia-correcting IOLs. In both rulings, Medicare provides coverage for conventional cataract surgery and permits the beneficiary to pay for noncovered items and services associated with refractive errors. Under the new guideline, your ophthalmologist can allow the patient to decide which IOL is best for his needs -- and you'll still get paid for it.

What to do: Medicare still considered the astigma- correcting IOL noncovered, but Medicare will pay up to the cost of a conventional IOL and the patient is then required to pay any amount exceeding that cost if he selects the astigma IOL.

"It is an unusual situation and doesn't really meet the ABN (advance beneficiary notice) definition, but Medicare is still going to provide partial coverage anyway," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. "I would think it best to obtain an ABN and make sure it has a full explanation as to patient responsibility (in layman's terms) on the form and the patient is aware of their partial financial responsibility for the special IOL."

Keep watch: CMS has said that more information on this new policy will be forthcoming. Ophthalmology Coding Alert will keep you up-to-date as more information becomes available.