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Additional payment for NTIOLs is coming soon
The impact of additional payments for NTIOLs is seen as positive for the Medicare program and its beneficiaries.
The Health Care Financing Administration (HCFA) has determined that some newer IOLs possess characteristics that are of great benefit to the Medicare patient population. As a result, they have agreed to pay an additional $50 premium for IOLs meeting the new technology criteria when implanted by physicians in a Medicare-approved ambulatory surgery center (ASC).
Starting in July 1999, manufacturers of new technology IOLs (NTIOLs) could submit their products to HCFA for additional payment evaluation. IOLs designated as NTIOLs before July 16, 2002 will be grouped by predominant characteristic, and the entire class will be eligible for additional payment during a 5-year period.
Background
Since the ASC benefit was first introduced by Medicare in 1982, the program has made payments for IOLs. From September 1982 to March 1990, Medicare reimbursed 80% of ophthalmologists’ reasonable charge for IOLs. In 1990, HCFA changed the ASC rate-setting methodology, creating the current system based on eight payment groups. Payment groups 6 and 8 were the only ones that included an IOL allowance ($200).
In 1993, an Office of Inspector General audit of IOL acquisition costs found that IOLs were readily available for less than $200. That led Medicare to reduce the IOL allowance to $150 in January 1994. Since then, reimbursement has remained at this level, and it is expected to continue at this rate until next year.
HCFA has the entire ASC payment structure slated for overhaul in mid-2000. Under proposed guidelines, 105 ambulatory payment classifications will replace the eight current ASC payment groups. In addition, the IOL allowance may decrease to $100.
New technology defined
NTIOLs are designated by HCFA as being approved by the Food and Drug Administration and having substantiated labeling and advertising portraying their specific clinical advantages and superiority over existing IOLs. The advantages attributed to NTIOLs include reduced risk of intraoperative or postoperative complication or trauma, accelerated postoperative recovery, reduced induced astigmatism, improved postop visual acuity, more stable postop vision and comparable clinical advantages.
IOLs meeting the new technology requirements will be divided into classes based upon their special characteristic such as “heparin-coated” or “multifocal.”
Once approved by HCFA, each NTIOL class will be assigned a temporary procedure code. The codes currently earmarked for NTIOLs are Q1001 through Q1005: New Technology Intraocular Lens Categories 1 through 5.
Once the first NTIOL in each category is assigned, the 5-year effective period begins for each class. For example, model QXR2000, the new IOL by XYZ Corporation, was the first model granted NTIOL status in Category X on Sept. 10, 1999. With the 5-year rule, the $50 NTIOL payment for Q100X will expire on Sept. 10, 2004. Any other IOL given new technology status in Category X also will expire on Sept. 10, 2004, even if the approval isn’t granted until May 2001.
HCFA will be publishing lists of approved IOLs with the appropriate category code in the Federal Register on a periodic basis. Ophthalmologists should be mindful of submitting claims for approved NTIOL codes only — submitting non-approved IOLs under approved NTIOL codes might be construed by Medicare as fraudulent.
The payment review process
Submitting an NTIOL for additional payment is a nine-step process:
1) HCFA publishes a notice in the Federal Register announcing deadlines and requirements for submitting a request for review.
2) HCFA receives requests.
3) HCFA compiles a list of all requests it receives, including a brief description of why the IOL should be considered for additional payment.
4) HCFA publishes a list of the above information in the Federal Register with a 30-day public comment period.
5) HCFA reviews all comments and determines if the IOL meets the definition of NTIOL.
6) If HCFA determines that the IOL meets the definition, it establishes a $50 payment adjustment.
7) HCFA designates a “class of new technology IOLs” based upon the predominant characteristic of the NTIOL.
8) Within 120 days of having published the list in the Federal Register, HCFA publishes its decision on the payment adjustment for a particular IOL.
9) The NTIOLs are eligible for the $50 payment adjustment 30 days after HCFA publishes its decision.
As with all Medicare billing and coding protocol, each provider is responsible for monitoring the Federal Register for the status of the IOL and incorporating that into his or her own billing process.
Filing claims for NTIOLs
NTIOLs can be billed to Medicare only when performed and billed by ophthalmologists using Medicare-approved ASCs. The place of service must be coded for an ASC (“24”), and the –SG modifier must be appended to the procedure code.
Claims for NTIOLs should be filed as two line submissions using the appropriate IOL insertion or cataract surgery code (CPT codes 66985, 66986, 66983 or 66984) and a procedure code for the NTIOLs (Q1001 through Q1005).
Claims submitted with only the NTIOL code will be considered incomplete and returned as unprocessable.
HCFA claims the financial impact of the new policy will be negligible; benefits of NTIOLs will save the Medicare program money in the long run with fewer returns to the operating room, fewer YAG capsulotomies and decreased need for post-cataract eyewear.
The payment allowance is a win-win situation for almost everyone. It is bound to reinvigorate the IOL industry and excite ASC owners. The only element to be determined is how many IOLs will be deemed NTIOLs.
For Your Information:
- David Steinberger is a reinbursement specialist with Eyecare Consultants Ltd., providing consulting and networking services to ophthalmologists and optometrists. The company is headquartered at 270 Amity Road, Ste. 220, Woodbridge, CT 06525. To receive further information on Medicare billing and coding advisory services, call (800) 633-6962; fax: (203) 389-4660; e-mail: neecare@aol.com.