Charging for ‘upgrade’ to Medicare service requires caution

NEW YORK — Physicians must be careful not to charge for noncovered “upgrades” to Medicare services in a way that makes it appear they are subsidizing their reimbursement for the Medicare covered service, according to Alan E. Reider, JD.

Mr. Reider, OSN Regulatory/Legislative Affairs Section Editor, spoke at the Ocular Surgery News Symposium about the complexities involved in billing for uncovered services associated with presbyopia correction performed in conjunction with Medicare-covered cataract surgery.

These issues have become important recently, Mr. Reider noted, because of the Centers for Medicare and Medicaid Services ruling that allowed Medicare patients to be billed separately for a portion of the cost of presbyopia-correcting IOLs and the diagnostic and surgical services required to choose and implant those lenses.

He said it is vital that, in billing for noncovered presbyopia-correction services performed at the time of cataract surgery in a Medicare patient, it does not appear that the surgeon is attempting to compensate for the low reimbursement for the covered surgical service.

“Physicians may take into account additional physician work and resources for inserting, fitting and visual acuity testing of presbyopia-correcting IOLs,” he said. “You know what you do [for these patients] beyond normal cataract procedures.”

He said additional charges billed separately to the patient for the noncovered services must appear to be reasonable in order to avoid the risk of violating rules that limit charges for surgeons who accept Medicare assignment.