Few products have captured the imagination of ophthalmologists as much as femtosecond-assisted cataract surgery. However, fascination has quickly turned to confusion as surgeons have tried to figure out exactly how they could get reimbursed for using the device. This article reviews how femtosecond laser cataract surgery is treated under the current Medicare guidelines, highlights reimbursement traps to watch out for and discusses how you can legally be reimbursed for the procedure.

Coding Confusion 

In 2012, the Centers for Medicare & Medicaid Services introduced two new category III codes covering the use of femtosecond lasers in corneal transplant surgery. However, their use is limited, and they have caused some confusion among surgeons, prompting calls to consultants and national societies regarding their proper use. Here is a rundown of the codes and how they are meant to be used. Note that the following comments apply when Medicare is the insurer. It’s best to check with individual insurance carriers in your area to see if their rules differ.

• Code +0289T. As written, this code is an add-on code applying to “corneal incisions in the donor cornea created using a laser, in preparation for penetrating or lamellar keratoplasty,” which should be listed separately in addition to a code for the primary procedure.

• Code +0290T. This is another add-on code, defined as “Corneal incisions in the recipient cornea created by a laser in preparation for penetrating or lamellar keratoplasty.

An ABN can ensure that patients understand which aspects of their surgery they'll be paying for themselves and which will be covered by insurance. 
When it comes to using the femtosecond laser in cataract surgery, there are two possible areas of confusion with these codes. First, since they’re category III codes, payment will be determined by the individual contractor or carrier. This means they can decide whether or not to cover it. Second, note that the codes don’t refer to the use of the femtosecond laser for cataract surgery, only corneal surgery. If an insurer were going to cover the codes, they would simply be add-on codes to a corneal transplant code. This is an important point because, even though transplant procedures are mentioned in the code description, surgeons have inquired about using the codes for cataract procedures and the validity of doing this. This code only applies to corneal transplant procedures, not cataract surgeries.

The Official Stance

As a framework for the discussion of femtosecond reimbursement, one should read the recent official statements issued by the American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology. The four surgical scenarios involving femtosecond-assisted cataract surgery are as follows:

• Medically necessary cataract extraction with implantation of a conventional intraocular lens. This is the most common cataract patient scenario and, unfortunately, neither the surgeon nor the surgical facility can bill the patient or Medicare extra for the use of the femtosecond laser in this situation. This is based on the definition of a global surgery procedure. The global surgery concept for a surgical procedure includes the incision, the procedure itself and the closure, no matter how those steps are accomplished. So, whether you use a femtosecond laser or a diamond knife, Medicare pays you the same fee.

Several years ago, before the femtosecond laser was put to use in the cataract arena, makers of another high-technology device, the Fugo Blade, petitioned CPT to get a code for the use of that device for making the incision during cataract surgery. They were turned down. Why? Because the functions performed by the Fugo Blade were already part of the global surgery and surgeons were not going to be reimbursed extra for doing them with a more expensive, high-technology device.

• Refractive lens exchange. This involves the non-medically necessary removal of the patient’s crystalline lens and then implanting an IOL for refractive purposes, such as for the correction of very high myopia. Since this is essentially a refractive procedure, which is classified by Medicare as a non-covered service, the surgeon and the facility may bill the patient for the use of the femtosecond laser. However, it’s important to be aware that CMS has regulations for the protection of beneficiaries, even if they’re undergoing a non-covered service. For this reason, be sure to check with a health-care attorney to make sure that the fee you charge for your femtosecond-assisted clear lens extractions is reasonable and fair, and couldn’t be viewed as price gouging.

• Medically necessary cataract surgery with the implantation of a premium refractive IOL. In this scenario, the surgeon or a surgical facility traditionally is allowed to charge the patient extra for the additional preoperative testing and general work and costs involved with implanting a premium IOL such as a multifocal, accommodating or toric lens.
The Practice Viewpoint
The model for the femtosecond-assisted cataract surgery practice is beginning to take shape, though it may undergo some modification before it becomes set. Currently, it appears that surgeons can use the device successfully and profitably as long as they’re careful about how they bill for it. 
Greensboro, N.C., surgeon Karl Stonecipher uses the LenSx laser at his practice, and says that so far it’s meshed well with the surgical options available to patients. “At our practice, any patient who gets a clear lens extraction, astigmatic correction, toric intraocular lens, multifocal lens or accommodating IOL gets the femtosecond laser because it’s part of our premium package,” he says.
Dr. Stonecipher says a variety of premium packages are available. “When it comes to the refractive lensectomy procedure, we charge the patient for everything,” he says. “I’m seeing more patients coming in for refractive lensectomy—usually having had LASIK, PRK or another refractive procedure in the past—and they’ve noticed that their vision has dropped, but their cataracts aren’t bad enough to warrant conventional surgery. They’re saying, ‘I’m not seeing well enough, and I want the vision I had before.’
“Then you get into the premium lenses,” Dr. Stonecipher continues. “The CMS ruling allows us to charge for the lens and the extra services involved with providing the lens. These charges include the cost of the lens, optical coherence tomography, topography, tomography, the extra chair time, etc. For instance, we get OCT exams on everyone getting a premium-package implantation because I don’t want to implant a multifocal IOL in someone with an idiopathic epiretinal membrane. However, you can’t put the femtosecond laser patient interface fee or the laser lease fee in the premium charge package. You have to figure out a way in your model to make it work. The other tier is using the laser for astigmatism correction only. We offer all patients some type of premium experience for 0.75 D or more of cylinder. The premium experience is all about trying to get them glasses-free.”
Dr. Stonecipher hopes the femtosecond-assisted corneal transplant codes the government created are a sign that femtosecond devices may be viewed differently by Medicare in the future, but he’s not so sure that they will be. “I think there may be this dichotomy in which Medicare may pay for [use of the femtosecond laser] for certain therapeutic procedures but not for others,” he muses. “Now there’s a CPT code for penetrating keratoplasty but they don’t reimburse you for using it with cataract surgery. I don’t understand how we have those two codes for keratoplasty but we don’t have a code for cataract surgery.”
This extra cost is billed to the patient, something he or she is made to understand and agrees to beforehand, when the premium lens is chosen. However—and here is where a fine distinction comes into play—the surgeon can’t specifically charge extra for the use of the femtosecond laser in this “premium package.” Again, this is because the functions performed by the laser are already under the umbrella of the global surgical fee that the surgeon receives from Medicare. As ASCRS and the AAO say in their official position papers on the femtosecond cataract laser: “Neither the surgeon nor the facility should use the differential charge allowed for implantation of a premium refractive IOL to recover all or a portion of the costs of using the femtosecond laser for cataract surgical steps. ... Patient-shared pricing with one cost for a premium IOL, and a higher cost for the additional use of the femtosecond laser to perform the cataract surgical steps, should not be offered. This would amount to charging the patient to use the femtosecond laser to perform covered components of the procedure.”

• Medically necessary cataract surgery, regardless of the lens implanted, that also involves femtosecond astigmatic keratotomy for refractive indications. This represents the intersection of the medically necessary cataract without astigmatism (where the use of the femtosecond laser is not reimbursable) and elective refractive indications (for which the surgeon and the facility can charge the patient extra for the use of the laser). As the ASCRS/AAO statement reads, “Medicare patients may be charged a fee for performing astigmatic keratotomy, assuming they were informed about, and consented to, the non-covered charges in advance. Because astigmatic keratotomy for refractive indications is a non-covered service, a higher fee can be charged for performing it using the femtosecond laser, instead of with a metal or diamond blade.”

Though Medicare doesn’t want providers to have patients fill out Advance Beneficiary Notices for routinely non-covered services such as in-office refractions, the practice should provide some written means for the patient to acknowledge his financial responsibility for non-covered services before surgery, and may use an ABN.

Since the laser and its use and maintenance are significant investments, performing laser AK on everyone with any amount of astigmatism might emerge as a way to recoup the investment in the technology. However, though CMS hasn’t ruled specifically on the amount of astigmatism correction that would be acceptable, it would have to be a reasonable amount of cylinder that has been documented preoperatively. As a possible guideline, various Medicare contractors and carriers have minimum amounts of astigmatism for which they will pay, falling under the heading of “correction of surgically induced astigmatism or astigmatism caused by trauma.” The minimums may differ, so it may pay to check with your local contractor/carrier to get a feel for what might be a legitimate amount. 

In light of the many questions surgeons have about femtosecond-assisted cataract surgery, it is hoped that this article gives practitioners the knowledge they need to confidently, and correctly, bill for the use of this exciting new technology.  REVIEW

Ms. Asbell is a clinical assistant professor of surgery (ophthalmology) at the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School.

Ms. Asbell provides coding advice to ophthalmic practices through her consulting firm, Riva Lee Asbell Associates, conducts instructional courses in coding around the country, and has written a book on the subject, “Tips on Surgical Coding by Subspecialty” which is available on her firm’s website: RivaLeeAsbell.com.