Q. What is blended vision?

A. Blended vision utilizes carefully selected conventional monofocal IOLs at the time of cataract surgery; one eye is corrected for distance and the other eye for near, providing excellent unaided vision following cataract surgery. The surgeon typically seeks emmetropia for the dominant eye and myopia for the nondominant eye. When both eyes are open, patients will not be aware of the difference between the two eyes and both distant and near objects will appear clear.  

Q. Will the patient enjoy spectacle independence?

A. Spectacle independence will rely on the patient’s tolerance for myopic defocus and interocular defocus.  

Q. What are the characteristics of a good candidate for blended vision?

A. Patients proceeding with blended vision cataract surgery must be fully informed about this approach and be motivated and carefully selected by the surgeon. Patients should understand that this is a compromise and that vision is not perfect either close up or far way. Stereopsis is diminished and some tasks may still require the use of eyeglasses.  

Q. Are there patients who would not be good candidates for blended vision?

A. Yes. Some patients should be excluded for a variety of reasons, including:
• Occupational requirements for stereopsis which might not be met with blended vision;
• The patient being a poor candidate for refractive keratoplasty to correct clinically significant astigmatism;
• Medical considerations that make blended vision success improbable (i.e., severe monocular loss of best-corrected vision unrelated to cataract);
• Intolerance of interocular defocus;
• Extraordinary expectations, which if frustrated, would result in a very unhappy patient.

Surgeons must recognize that blended vision is not appropriate for everyone.

Q. What is the best approach for the surgeon to determine if a patient is a suitable candidate for blended vision?

A. The surgeon must determine the extent of the patient’s motivation. Asking patients to complete a questionnaire assessing the patient’s vision requirements during normal day-to-day activities is a good way to evaluate suitability. Ask patients to rank their personality. Are they easy-going or a perfectionist, or somewhere in the middle? 

This information is extremely valuable in determining a good blended vision candidate; answers to these questions help the surgeon determine the amount of spectacle independence desired by the patient.  

Q. Are there tests performed to determine patient suitability?

A. Yes. There are a series of preoperative tests that are refractive in nature. These tests include, but are not limited to, ocular dominance, stereopsis and interocular defocus threshold. The unit of measure for these tests is diopters. Keep in mind that suitability for blended vision relies on matching patient expectations to tolerance for imbalance between the two eyes.  

Q. Are there other tests that may be performed in addition to the refractive tests?

A. The decision to perform additional testing is up to the individual surgeon. Some may choose to perform corneal topography, screening OCT and/or wavefront aberrometry. This list is not exhaustive.  

Q. Are these tests covered by Medicare?

A. No. Medicare and most other third party payers do not cover refractions and related refractive tests. Corneal topography for regular astigmatism is also non-covered, as is screening OCT.  

Q. If these tests are non-covered, may patients be billed for them?

A. Yes. Patients should be educated on the non-covered services and associated charge(s). They should expect a modest out-of-pocket expense for the tests performed. Out-of-pocket costs may be higher if additional surgery is needed to correct corneal astigmatism.

 Should patients sign a waiver agreeing to the out-of-pocket expense?

A. Yes. While payment for non-covered services is the beneficiary’s obligation, the Medicare law contains a provision that waives that liability if the beneficiary is not likely to know, and did not have a reason to know, that the services would not be covered. To adequately address the economic considerations of refractive cataract surgery with blended vision, the patient’s financial responsibility for the non-covered services must be carefully delineated and agreed upon. Surgeons may choose to notify a beneficiary that these services are never covered using the Advance Beneficiary Notice (ABN) or a Notice of Exclusion from Medicare Benefits (NEMB, Form CMS-20007).  

Q. Is there a CPT code for the preoperative refractive testing? 

A. These refractive tests can be coded with the refraction code, 92015. Because the refraction is also accompanied by a series of related tests, adding modifier 22, unusual procedural services, to the CPT code is recommended. This modifier indicates an atypical service, which warrants a higher charge than the usual and customary refraction charge.  

Q. Am I compelled to file a claim to Medicare for the refractive tests?  

A. No; if the patient wants to see a denial from Medicare, 92015-22 with modifier GY and a refractive diagnosis can be submitted. Modifier GY identifies that the service is not a Medicare benefit and is therefore non-covered. 

Q. How do I determine a reasonable charge for the non-covered services associated with blended vision?

A. Under the principle of assignment of benefits, the amount that is charged is often much higher than the amount that is paid, sometimes dramatically. For non-covered services, this is not the case. Nevertheless, surgeons should not presume that “the sky’s the limit” for practical reasons (the patient will seek care elsewhere) and because the charges need to be reasonable and defensible. One way to judge the propriety of a charge is whether it is consistent with what the physician would otherwise charge a self-pay patient for the same services.

Q. Are these tests performed more than once?

A. Maybe. All of these tests are performed prior to the first cataract surgery and some may need to be repeated prior to surgery on the fellow eye.

Q. If the patient also requires astigmatic correction and wants a claim filed for it, is there a CPT code for this component?

A. The CPT handbook does not have a specific code to describe surgical correction of pre-existing astigmatism, not surgically induced. The only code available is 66999, unlisted procedure, anterior segment of the eye. This would also be submitted with modifier GY and an astigmatism diagnosis for this service.  REVIEW

Ms. McCune is vice pres­ident of the Cor­coran Con­sult­ing Group. Con­tact her at DMcCune@corcoranccg.com.