Astigmatic keratotomy

Cosmetic refractive surgery is not covered by Medicare, even when bundled.

The National Correct Coding Initiative bundles a number of procedures with cataract surgery when performed during the same operative session, including corneal relaxing incision for correction of surgically induced astigmatism (65772) and corneal wedge resection for correction of surgically induced astigmatism (65775).

You plan to perform astigmatic keratotomy at the time of cataract surgery for a patient with existing astigmatism.

Is astigmatic keratotomy bundled with cataract surgery?

For the patient with an operable cataract and astigmatism, combining a cataract extraction with IOL implant and astigmatic keratotomy can reduce or eliminate reliance on postoperative corrective lenses. This is an attractive option for patients, but there are several clinical and reimbursement considerations to be addressed before scheduling surgery.

Astigmatism can be either iatrogenic or pre-existing. Iatrogenic astigmatism is induced by the effects of treatment, usually surgery. A pre-existing astigmatism is not induced by a previous surgery.

Medicare pays for a variety of services including surgery, but there are indications and limitations of coverage. Reimbursement is made for services Medicare believes to be medically necessary. Medicare’s empowering legislation, contained in the Social Security Act, includes §1862(a)(1), which states that “no payment may be made under Part A or Part B for any expenses incurred for items or services which … are not reasonable and necessary for the diagnosis or treatment of illness.”

Medicare does not pay for cosmetic or refractive surgery. In rare instances, Medicare covers refractive surgery to correct a surgical complication (MCPM, Chapter 12, §40.1B) or to treat the resulting refractive error due to trauma (Transmittal 99). This regulation is based on a statutory provision contained in the Social Security Act §1862(a)(10), which states that “no payment may be made under Part A or Part B for any expenses incurred for items or services … where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member.”

Refractive surgery performed solely to reduce the patient’s dependence on eyeglasses or contact lenses would be considered cosmetic in Medicare’s view and therefore excluded from coverage. Furthermore, the Medicare National Coverage Determinations Manual contains specific instructions about refractive surgery in NCD §80.7, which specifies that “keratoplasty for the purpose of refractive error compensation is considered a substitute or alternative to eyeglasses or contact lenses, which are specifically excluded. … keratoplasty to treat refractive defects are not covered.”

Astigmatic keratotomy is a form of keratoplasty, and corneal relaxing incisions or limbal relaxing incisions are two commonly known astigmatic keratotomy procedures.

You do not need an Advance Beneficiary Notice for services that are statutorily (by law) noncovered by Medicare. Statutorily noncovered services in an eye care practice include refractions and cosmetic surgery. A Notice of Exclusions from Medicare Benefits form notifies the patient that this service is noncovered and that the patient will be responsible for the charges associated with the procedure. By signing a form, the patient accepts financial responsibility and elects to proceed.

Pre-existing astigmatism is not an indication for either of the two procedures described above (65772, 65775). The CPT handbook does not have a specific code to describe astigmatic keratotomy on an eye with pre-existing astigmatism not surgically induced. A miscellaneous code, Unlisted procedure, anterior segment of the eye (66999), is the only code available to describe surgery for pre-existing astigmatism (See figure above).

Add modifier -GY to procedure code 66999 on the CMS-1500 claim form to notify the carrier that you performed a statutorily excluded procedure, and the beneficiary requested the physician to file a claim anyway. Filing a claim for an excluded procedure is useful, but not mandatory, because the explanation of benefits sent to the patient shows that the procedure is not covered. In addition, some patients have supplemental insurance that might cover the procedure.