Patients may pay for refractive 'extras' in cataract surgery

September 1, 2005

When removing a cataract, surgeons have an opportunity to perform other vision-correcting procedures. However, that scenario leads to what can be a delicate subject—who's going to pay for those "extras?"

Although Medicare and many third-party payers will not cover any procedure not deemed medically necessary, there is often a third option: the patient.

Donna M. McCune, CCS-P, COE, vice president, Corcoran Consulting Group of San Bernardino, CA, said covered and non-covered procedures can be combined during a single surgery, as long as the patient is fully aware that he or she will be required to pay for the non-covered service.

In these cases, she recommended that practices use proper paperwork to document cases and spell out who is financially responsible for each portion of the surgery.

What is covered?

Medicare is bound by the Social Security Act to refuse payment for "expenses incurred for items or services which . . . are not reasonable and necessary for the diagnosis or treatment of illness." Most insurance companies only cover surgery if it is medically necessary.

In a presentation during the Current Concepts of Ophthalmology meeting in Dorado, Puerto Rico, McCune offered two case studies to demonstrate what is covered and what is not. Third-party payers will cover cataract surgery if the patient has blurred vision, difficulty with reading and driving, and problems with daily living, and glasses offer no help, with best-corrected visual acuity (BCVA) of 20/50 or worse and nuclear cataracts, she said.

The patient should have a good prognosis for improvement, and be able to tolerate anesthesia. Practices should consider asking patients to complete a questionnaire to determine the extent to which their lifestyle is diminished by the cataract, she said. However, third-party payers will not cover a case of a patient who has good vision, except for occasional glare at night, with a BCVA of 20/20 or 20/25 with glare, presbyopia, and an incipient cataract, noted McCune during the meeting that was sponsored by Johns Hopkins University School of Medicine, Baltimore, and Ophthalmology Times.

Medicare will pay for the exam or consultation to determine the need for medically necessary surgery, one form of biometry [A-scan (code 76519) or optical coherence biometry (code 92136)], a surgeon's global package (preoperative, postoperative, and intraoperative care), and anesthesia.

For the facility, Medicare reimburses for:

Until May, when the Centers for Medicare and Medicaid Services (CMS) began allowing cataract patients to pay extra for a presbyopia-correcting lens, the agency prohibited patients from receiving "deluxe features"-even if they were willing to pay for them. For the last 5 years, Medicare did pay ambulatory surgical centers an extra $50 if they used new technology IOLs (NTIOLs)-Array (AMO) and STAAR Surgical's Toric lens. The NTIOL status for these lenses expired in May.

Surgeons may charge the patient for limbal-relaxing or cornea-relaxing incisions to correct pre-existing astigmatism, if the patient is informed ahead of time and agrees to proceed. In these cases, McCune warned practices to use the miscellaneous code 66999 rather than the code for surgically induced astigmatism (65772).

Practices must be very careful to inform patients-and prove they have informed them-about any expenses for which they might be liable, or the practice could be on the hook.