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How to Correctly Code and Bill for Premium IOLs

Watch out for these potential problem areas

BY STEPHANIE ELLIS, RN | AUGUST 2019

Several compliance issues could come up with the use of intraocular lenses (IOL) used in cataract cases performed on Medicare patients in ASCs. These compliance issues involve the use of premium lenses. When a Medicare patient has a presbyopia-correcting (PC) IOL or an astigmatism correcting (AC) IOL inserted instead of a regular IOL, there are special guidelines which must be followed by ASCs and ophthalmology practices to stay in compliance with Medicare guidelines.

Billing Correctly

First, even though Medicare does not reimburse ASCs any more for the use of premium lenses in their cataract cases than they do for regular IOLs, the ASC still needs to indicate on their Medicare claim form that a premium lens was used in the case. Bill the premium lenses using the V2788 code for PC IOLs or the V2787 code for an AC IOL. Append the –GY Non-Covered Modifier and/or the -GA Modifier to the V-code to indicate that you don’t expect payment for the IOL and that you have had the patient sign an Advanced Beneficiary Notice (ABN form or waiver) and that the patient understands he/she will have the remainder amount owing for the use of the special premium lens as an out-of-pocket expense. While it is not mandatory to have the patient sign an ABN, since the PC and AC IOLs are never covered by Medicare, it is a good idea so that there will be no misunderstandings with Medicare patients of his/her owing portion.

Medicare Reimbursement to ASCs for IOLs

When ASCs bill the 66984, 66982 or other cataract extraction procedure code to Medicare, those codes include the insertion of an IOL in the cataract procedure, and the payment of the cataract CPT code to ASCs includes a $150 allowance as payment for a regular IOL. That does not change when premium lenses are used in the case. ASC facilities are still being reimbursed for the placement of an IOL in the cataract procedure.

Compliance Issues Involved with Using Premium Lenses

Following are the areas where compliance issues come up with these types of cases:

1. When the surgeon wants to purchase the premium lens for the case and bring it into the ASC for use in the case, it is a compliance issue. Medicare does not allow ASCs to bill for cataract extraction procedures with placement of an IOL with the -52 Reduced Services Modifier or using any other billing method to convey to Medicare that the ASC did not supply the IOL and, therefore, should not be reimbursed for the IOL supply. Since there is no provision to allow the ASC to break out the implant portion of the procedure from the cataract surgery itself, Medicare requires that the ASC facility must supply the IOL for all Medicare cataract cases. Medicare considers it to be a false claim for the ASC to submit a cataract extraction claim for which they are receiving payment for the IOL when the ASC is not supplying the IOL for the case.
2. Medicare does not allow ASCs to reimburse physicians for IOLs if the IOL was supplied by the physician in a cataract case. The IOL must be purchased and supplied by the ASC facility for all cataract cases using regular or premium lenses for Medicare patients.
3. When ASCs correctly purchase premium lenses for a Medicare patient’s cataract case and the surgeon wants to collect the owing portion related to the use of a premium lens from the patient, a compliance issue could arise. Ophthalmologists cannot charge the patient and collect money from a Medicare patient for premium lens implants used in cataract surgeries performed at an ASC. Medicare considers this to be a fraud issue for both the ASC and the physician practice. An ASC must collect the money related to the IOL directly from the patient.
4. When an ASC charges a patient for the difference between the $150 Medicare reimburses the ASC for the IOL and the full lens cost of a premium lens, it could be a compliance issue. What an ASC charges Medicare patients for a premium lens must be handled correctly to stay out of trouble with Medicare, since it directs what an ASC can charge patients in these types of cases. ASCs need to be sure that they aren’t overcharging Medicare patients for premium lenses.

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:

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.

Stephanie Ellis, RN, is the president of Ellis Medical Consulting Inc. in Franklin, Tennessee. Write her at SEllis@EllisMedical.com.

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.