Health Information Management

Identify new intraocular lenses for which ASCs can bill patients directly

JustCoding News: Outpatient, September 23, 2009

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by Stephanie Ellis, RN, CPC

In August, Medicare added several new intraocular lens (IOL) models to the New Technology IOL (NTIOL) list that ambulatory surgery centers (ASC) can bill to Medicare using HCPCS code Q1003 (New technology intraocular lens category 3 [reduced spherical aberration]).

Medicare added the following NTIOL models in August:

  • Bausch & Lomb: Akreos® AO
  • Bausch & Lomb: Akreos® MI60
  • Hoya: FY-60AD
  • Hoya: FC-60AD
  • Alcon: Acrysof® IQ Toric Model SN6ATT

Understand new reimbursement policies

The addition of the Alcon Toric lens presents some significant reimbursement challenges for facilities. Typically, ASC facilities cannot charge patients an extra amount for use of special IOLs beyond what Medicare reimburses for those IOLs. Medicare’s payment for cataract extraction codes 66982, 66983, and 66984 includes $150 for the lens and an additional $50 for code Q1003 for an NTIOL.

Facilities have had the ability to charge Medicare patients the difference between their cost for a presbyopia-correcting (PC) IOL lens (HCPCS code V2788) minus the $150 that Medicare reimburses as part of the payment for cataract procedure codes 66982, 66983 and 66984. Also, previously, the same procedure could be used for astigmatism-correcting (AC) IOL lenses (HCPCS code V2787). Therefore, historically, PC and AC IOLs have been the only types of lenses for which providers could charge Medicare patients directly.

Prior to this change in August, providers could not charge Medicare patients any additional cost for the use of regular anterior or posterior chamber IOLs. They also couldn’t charge extra for all NTIOLs other than the patient’s usual co-payment and deductible amounts for the cataract procedure itself.

Medicare’s requirements of not charging Medicare patients extra applies to these models of NTIOLs that were previously on Medicare’s list for use with code Q1003 and continue to remain as such:

  • Tecnis® models Z9000, Z9001, Z9002 and ZA9003, also AR40xEM and ZCB00 manufactured by Advanced Medical Optics
  • AcrySof® IQ SN60WF and Acrysert™ SN60WS by Alcon
  • Sofport® models LI61AO and LI61AOV by Bausch & Lomb
  • Affinity™ Collamer® CQ2015A, CC4204A and Elastimide™ AQ2015A by STAAR

The addition of the AC IOL Toric lens to the list of NTIOLs that fall under HCPCS code Q1003 marks a significant change from previous policies. Even though Medicare has added Toric lenses to the list of NTIOLs, its policy that providers can charge patients directly for the difference in the cost and Medicare’s reimbursement still applies to the Toric lens.

Note Toric lens billing example

Following is an example of how to correctly charge a Medicare patient for a Toric lens:

  $500 Approximate cost of the Toric lens to the facility
-$150 Medicare reimbursement for regular IOL as part of cataract CPT code
-  $50 Extra $50 that Medicare reimburses for the use of an NTIOL with code Q1003
  $300
+  $50 ASC’s cost for shipping and handling of lens ($50 maximum)
– Modest mark-up
  $350 Final suggested maximum amount ASC can charge a Medicare patient

Because facilities could charge patients for the difference, Medicare strongly recommends that they ask patients to sign an Advance Beneficiary Notice (ABN) form or waiver.

Facilities must purchase and supply IOLs

Be aware that for cataract extraction procedures performed in an ASC, surgeons cannot purchase IOLs for these cases and bring them into the facility. This would present a significant compliance problem for both the facility and the surgeon.

Medicare does not allow the facility to append modifier -52 (Reduced services) to bill for cataract extraction procedures. It also doesn’t allow any other billing method to convey to Medicare that the facility did not supply the IOL and therefore shouldn’t be reimbursed for it.

Because there is no provision to allow facilities to separate the implant portion of the reimbursement for the cataract extraction CPT code, Medicare requires facilities to supply the IOL for cataract cases performed on Medicare patients. When a facility submits a cataract extraction claim for which it receives payment for an IOL even though it did not supply the IOL, Medicare would consider this a False Claim.

Likewise, Medicare does not allow facilities to reimburse physicians for IOLs, so it’s important to note that facilities must purchase and supply IOLs for all cataract case claims filed to Medicare.

Overcharging patients for the PC IOLs or Toric lenses can be a compliance problem. Therefore, facilities need to ensure that they aren’t charging Medicare patients more than the $50 maximum mark-up for these lenses. The same goes for AC IOLs. Medicare allows facilities only a modest mark-up ($25–$50) for the IOL for shipping and handling.

Review your internal processes for these cases to ensure you’re handling them in a compliant manner.

Editor’s note: Stephanie Ellis, RN, CPC, is the president of Ellis Medical Consulting, Inc., in Brentwood, TN. E-mail her at sellis@ellismedical.com.



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