Billing and coding issues related to presbyopia-correcting IOLs

Issue: March 1, 2006

ByE. Ann Rose

Previous articles have discussed the coverage and noncoverage issues surrounding the new presbyopia-correcting IOLs. This article is intended to address only the billing and coding issues involved with the new IOLs. Even though certain services provided in conjunction with presbyopia-correcting IOLs are considered noncovered by Medicare, they are being performed in conjunction with a Medicare-covered service, ie, medically necessary cataract surgery. Providers should make sure their billing and documentation reflect the additional noncovered services that are being billed to the patient or the insurance.

1. Is there a specific code we should use to report noncovered services performed in conjunction with a presbyopia-correcting IOL?

E. Ann Rose

CMS Transmittal 801, dated Dec. 30, 2005, indicates the new HCPCS Code V2788, Presbyopia correcting function of an intraocular lens, may be used to report the noncovered services associated with the insertion of a presbyopia-correcting IOL. The new code is effective for dates of service on or after Jan. 1, 2006.

Providers, hospitals and ASCs may report this code on claims to reflect those additional charges for the presbyopia-correcting IOL when inserted in lieu of a conventional IOL. Since the ASC or hospital facility fee payment includes $150 for the conventional IOL, it is important for the facility charges to reflect only noncovered services not otherwise included in the Medicare allowed amount for a conventional IOL. Code V2788 also can be used to bill the patient directly for the noncovered presbyopia-correcting services.

2. Are cataract codes 66982, 66983 and 66984 the only codes that can be used to report the insertion and replacement of a presbyopia-correcting IOL subsequent to cataract surgery?

No. CMS Transmittal 801 also added two additional procedure codes (66985, Insertion of IOL not associated with concurrent cataract surgery, and 66986, Exchange of IOL) to the current list of allowed codes for this surgery.

3. Do we have to file a claim to Medicare for the noncovered services provided for presbyopia-correcting IOL patients?

You are not required to bill Medicare unless the patient asks you to do so for a secondary insurance denial. Some patients may have secondary insurance that will pay for the noncovered services and need the Medicare denial for the services to be considered.

Alan E. Reider, JD [photo]
Alan E. Reider

Allison Weber-Shuren, JD [photo]
Allison Weber-Shuren

4. What diagnosis should we use with Code V2788? What about special modifiers?

The diagnosis for Code V2788 should be 367.4, Presbyopia, not cataract. Since CMS has instructed Medicare carriers to deny Code V2788 automatically as a noncovered service, no modifiers should be needed. However, some carriers may still require the service to be billed with the -GY modifier to indicate an excluded, noncovered service.

5. Am I required to furnish the patient with an Advance Beneficiary Notice (ABN) regarding the noncovered services?

Since presbyopia-correcting IOL functionality does not fall into a Medicare benefit category, the physician and facility are not required to provide an ABN to patients who request this service. CMS strongly encourages physicians and facilities to issue a Notice of Exclusion from Medicare Benefits (NEMB). A sample notice can be downloaded from the CMS website at www.cms.hhs.gov. Just do a search for “NEMB.”

6. What about patients with insurance other than Medicare? How do I bill those claims?

As with Medicare, commercial carriers have historically bundled the IOL payment into medically necessary cataract surgery. Some commercial carriers have recently developed policies similar to Medicare, which permit physicians to bill the patient directly for services performed in conjunction with a presbyopia-correcting IOL. Some carriers, however, still restrict “balance billing” the patient any differences in the contracted fees. If unsure about how to bill commercial carriers, physicians and facilities should contact the payer about their specific policy.

For Your Information:

E. Ann Rose is president of Rose & Associates, a consulting firm specializing in Medicare billing and coding issues. She provides answers to frequently asked questions regarding how to bill and code for presbyopia-correcting IOLs. She can be reached at Rose & Associates, 402 W. Wheatland, Suite 150, Duncanville, TX 75116; 800-720-9667; fax 972-780-8546.

Alan E. Reider, JD, can be reached at Arent Fox PLLC, 1050 Connecticut Ave. NW, Washington, DC 20036; 202-857-6462; fax: 202-857-6462.