For example, if a Crystalens PC IOL is used in a cataract case and the cost for the lens is $1,100, what the ASC charges a Medicare patient for the IOL must be carefully calculated. Keep in mind that the ASC is receiving the $150 for the IOL used in the surgery from Medicare as part of the cataract extraction CPT code, so that amount must be subtracted from the amount charged to the patient. Medicare allows only a modest mark-up on the IOL for handling ($25-$50 maximum). Medicare does not allow patients to be charged a massive mark-up (2-3 times cost or more) on premium lenses.
Following is an example of how to correctly charge a Medicare patient for a premium lens:
||Medicare reimbursement for regular IOL
||ASC’s cost for handling of lens (markup)
||Final maximum amount the ASC can charge a Medicare patient
The only extra charges separate from the surgeon’s normal surgical fee for performing a cataract surgery that ophthalmologists can charge Medicare patients in a case involving a premium lens is for his/her professional service for adjusting the premium lens. The physician is not to be involved in any way in the lens transaction with the patient.
Since physicians can purchase and bring implants into ASC facilities for many other types of cases (i.e., breast implants, etc.), it can seem like it would not be a problem to do the same with these premium lenses. However, it is a process which must be handled differently because of the bundled payment to ASCs for the IOL in the cataract extraction CPT code for Medicare patients. Thus, ASC facilities and ophthalmology practices might want to review their internal processes on the use of premium lenses and be sure they are handling these cases in a compliant manner to stay out of trouble with Medicare.
The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion.