Q: Will Medicare reimburse for astigmatism correction during cataract surgery?
A: Medicare does not pay for cosmetic or refractive surgery except in rare instances when refractive surgery may be covered to correct a surgical complication (MCPM, Chapter 12, §40.1B) or treat the resulting refractive error due to trauma (Transmittal 99).
Medicare may, however, consider the correction of iatrogenic astigmatism to be covered. The effects of treatment, usually surgery, sometimes induce iatrogenic astigmatism. The mere existence of iatrogenic astigmatism does not in itself make astigmatic correction a covered service. The clinical notes would include a discussion regarding trial of spectacles and contact lenses without success.
Q: Which CPT codes describe the correction of surgically induced astigmatism?
A: The CPT handbook describes two: 65772, Corneal relaxing incisions for correction of surgically induced astigmatism; and 65775, Corneal wedge resection for correction of surgically induced astigmatism. In general, wedge resection is used for large amounts of astigmatism and relaxing incisions are used for smaller corrections.
But there is little guidance on what amount of surgically induced astigmatism Medicare considers medically necessary, which would allow reimbursement. Few Medicare carriers have Local Coverage Decisions (LCDs) that specify such an amount, and the LCDs that do exist have varying thresholds for coverage; some do not specify at all. In cases where coverage is uncertain, an Advanced Beneficiary Notice is warranted.
Q: If we correct pre-existing astigmatism (not surgically induced) with an AK, LRI or CRI at the time of cataract surgery, is it bundled in with the cataract surgery?
A: No. The correction of pre-existing astigmatism not surgically induced is considered refractive surgery. Medicare deems refractive surgery solely to reduce the patient's dependence on eyeglasses or contact lenses to be cosmetic and, therefore, excluded from coverage. The patient is financially responsible for this refractive procedure.
Q: How do we distinguish this noncovered procedure from a covered cataract surgery?
A: Although not required, it is highly recommended that the patient sign a Notice of Exclusion from Medicare Benefits (NEMB). This form signifies the patient's understanding that this procedure is refractive and noncovered, and he or she agrees to be financially responsible. For bookkeeping purposes and to keep it distinct from the covered service, use code 66999, Unlisted procedure, anterior segment of the eye to describe the procedure.
Q: Do I need to include this procedure on the Medicare claim form?
A: Although not mandatory, filing a claim for an excluded procedure is useful because the explanation of benefits (EOB) sent to the patient shows that the procedure is not covered. Some beneficiaries may request that the claim be filed because they have supplemental insurance that might cover the procedure. If filed, add modifier GY to procedure code 66999 on the CMS-1500 claim form to notify the carrier that you performed a statutorily excluded procedure.
Q: Does Medicare make a distinction between a toric IOL and a conventional IOL?
A: Staar Surgical and Alcon manufacture and distribute toric IOLs, designed to correct both sphere and cylinder for patients with pre-existing corneal astigmatism.
Toric IOLs (specifically the Staar lens) were previously considered new technology IOLs from May 18, 2000 to May 18, 2005, and ASCs received an additional $50 for this IOL.
On January 22, 2007, a CMS ruling distinguished these lenses as having a "deluxe" component for the astigmatism-correcting functionality. In plain terms, the Medicare program allows beneficiaries to purchase an upgrade from a conventional IOL to an astigmatism-correcting IOL and pay additional charges beyond those associated with standard cataract surgery.
Q: What additional charges are associated with the implantation of a toric IOL?
A: The facility may charge the patient for the additional cost of the IOL. Keep in mind that Medicare covers a portion of the IOL, and a portion is non-covered. As a point of reference, Medicare has valued IOLs at $150 in its determination of ASC payment rates, so the covered portion is part of the standard facility fee. Therefore, the non-covered charge to upgrade to a deluxe IOL is any additional charge beyond $150. If there is markup on the IOL, it should be very modest to account for shipping, handling, sales tax, etc.
The surgeon may also charge for additional services associated with implanting a toric IOL, such as refraction, topography, wavefront aberration testing and marking the axis of astigmatism on the eye at the outset of cataract surgery. This list is not exhaustive, and each physician will develop an individual protocol and associated charge.
CMS highly recommends the use of an NEMB to clearly identify the non-covered items and services and the associated fees. The facility and surgeon should each execute a separate NEMB. Medicare does not require reporting of non-covered items or services. For the sake of clarity and line-item bookkeeping, it is useful to assign codes to these non-covered items to track them internally.
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.