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Are You Billing for your PC/AC IOL Cataract Cases Correctly?

Did you know that when your ASC facility has a Medicare patient who requests a Presbyopia-Correcting (PC) IOL lens or an Astigmatism-Correcting (AC) IOL lens (instead of a regular IOL) that there are special guidelines that must be followed to stay in compliance with Medicare guidelines? This can be an important compliance problem you can have without even knowing it, so make sure these cases are being handled correctly at your facility.


Billing correctly
First of all, even though Medicare won’t reimburse any more than they usually do for regular IOLs for these cases — the usual reimbursement of $150.00 is included in the payment of the 66984, 66982, etc. CPT catract procedure codes — you still need to indicate on the claim form that the PC or AC IOL was used in the case. Bill these special IOLs using the V2788 code for the PC IOL (ReStor, ReZoom and Crystalens) or the V2787 code for an AC IOL (Toric Lenses). It is advisable to append the -GY non-covered modifier and/or the -GA modifier to the appropriate V-code to indicate you have had the patient sign an Advanced Beneficiary Notice (ABN form or waiver). You do not have to have patients sign an ABN since the PC and AC IOLs are never covered by Medicare, but it is a good idea to still have them sign the ABN so that there will be no misunderstandings with patients on their owing portion.

Medicare reimbursement
When you bill the 66984, 66982 or other Cataract Extraction procedure code to Medicare, understand that those codes include the insertion of an IOL in the procedure, and that the payment of the cataract CPT code includes a $150.00 allowance for payment of a regular posterior chamber or anterior chamber IOL. That does not change when you use the PC or AC IOLs in the case, instead of a regular IOL. Your facility is still being reimbursed for the placement of an IOL. Even though it is a different type of IOL, it does not change that you have been paid for the IOL by Medicare.

What are the compliance issues?
Where do the compliance issues come up with these types of cases?

1. When the surgeon wants to purchase the PC or AC IOL for the case and bring it into the ASC for the case, it is a compliance issue. Why? Because Medicare does not allow the ASC to bill for cataract extraction procedures with placement of an IOL with the -52 reduced services modifier or the use of any other billing method to convey to Medicare that the ASC did not supply the IOL and should not be reimbursed for the IOL supply. Since there is no provision to allow the ASC to break out the implant portion of the procedure from the cataract extraction, Medicare requires that the facility must supply the IOL for these cataract cases. Medicare considers it to be a False Claim for the ASC to submit a cataract extraction claim for which they are receiving payment for the IOL when the ASC is not supplying the IOL.

2. Medicare does not allow the ASC facility to reimburse the physician for the IOL if the IOL was supplied by the physician in these cases. The IOL must be purchased and supplied by the ASC facility for these cases.

3. Did you know that what you charge patients for the use of the PC or AC IOLs can potentially raise another compliance issue? Did you know that Medicare directs what you can charge patients in these cases? Overcharging patients for these lenses can be a compliance issue. Therefore, you need to be sure you aren’t overcharging Medicare patients for these PC and AC lenses. For example, if the Crystalens PC IOL is used and your facility’s cost for the lens is $1,100, what can you charge the Medicare patient for the IOL? Keep in mind that you are receiving the $150.00 as usual for the IOL from Medicare as part of the cataract extraction code, so that amount must be subtracted from the amount you charge the patient. Medicare allows you only a modest mark-up on the IOL for handling. That is all you can charge the patient. Medicare does not allow you to charge the patient a massive mark-up (2-3 times cost or more) on these lenses.

Here is an example of how to correctly charge a Medicare patient on a PC or AC IOL for these types of cases:

$1,100.00    Lens cost
- $150.00 Medicare reimbursement for regular IOL
$950.00
+ $50.00 ASC’s cost for handling of lens
$1,000.00    Final suggested maximum amount ASC can charge patient

Since physicians can purchase and bring in implants for many other types of cases (i.e., breast implants, etc.), it can seem like it would not be a problem to do the same for these cataract extraction procedures involving PC and AC IOLs; however, it is a process which must be handled differently due to the bundled payment for the IOL in the cataract extraction CPT code. Thus, you might want to review your internal processes on these cases and be sure you are handling these cases in a compliant manner.

Note: CPT codes are copyrighted by the AMA.

Ms. Ellis (sellis@ellismedical.com) is president of Ellis Medical Consulting (www.ellismedical.com), a healthcare consulting firm providing chart audits for coding and documentation issues, business office operational assessments, research of coverage issues, fee and coding revisions, litigation support, reimbursement research, coding/billing training, and the development and implementation of billing compliance programs for healthcare providers.

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