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CMS ruling positions cataract surgery at the gateway to presbyopia correction
The decision on presbyopia IOL reimbursement redefines the refractive component of cataract surgery, thereby halting refractive bracket creep.
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It is difficult to overstate the importance for cataract surgeons of the recent CMS ruling allowing a private pay option for presbyopia correction. Besides acknowledging the value of a new generation of reading vision IOLs, this ruling goes further by formally recognizing the added refractive components of cataract surgery utilized specifically to enable lens implant presbyopia correction as a constellation of optional, uncovered services by the surgeon.
With this ruling, refractive cataract surgery has been redefined, and the critical decoupling of refractive and cataract surgery is now in place. The insidious and unsustainable refractive bracket creep of the past decade, wherein significant refractive value was continuously incorporated into “routine” cataract surgery while reimbursements declined precipitously, is finally halted at the threshold of lens implant presbyopia correction. This ruling reorganizes cataract surgery into either a fully covered nonrefractive treatment approach, intended to address the visual impairment resulting from a lens opacity, or a partially covered refractive treatment approach, with additional optional corrective measures designed to restore reading vision for which the patient may elect to pay separately. From this point on, refractive cataract surgeons are no longer cataract surgeons only when it comes to reimbursement.
![OSN Lens-Based Refractive Surgery [logo]](/images/commonart/refractive.gif)
A look at the CMS ruling
I recommend that you read this ruling in its entirety. Here are excerpts from the central elements of the May 3 ruling. The ruling could not be more clear in its key assertion that presbyopia correction constitutes an uncovered service.
“Presbyopia [is] a type of refractive error … Therefore, the presbyopia-correcting functionality of an IOL does not fall into the benefit category and is not covered.”
Consequently, the additional costs for a premium IOL and those physician services, both surgical and ancillary, specific to presbyopia correction are uncovered and may be paid separately by those patients who elect optional presbyopia treatment.
Regarding the added costs of a premium IOL used to correct presbyopia within a hospital or Medicare-approved ASC, where the IOL cost is bundled in the facility charge:
“… the facility charge for insertion of the presbyopia-correcting IOL is considered partially covered. The beneficiary is responsible for payment of that portion of the facility charge that exceeds the facility charge for insertion of a conventional IOL …”
Regarding the added costs of a premium IOL used to correct presbyopia within a physician’s office, where the IOL cost is treated separately:
“… the presbyopia-correcting IOL device is considered partially covered. The beneficiary is responsible for payment of that portion of the physician’s charge for the presbyopia-correcting IOL that exceeds the physician’s charge for a conventional IOL …”
Regarding the additional physician services specific to presbyopia correction (this is the most important element of this ruling for the surgeon):
“The payment amounts for the IOL device and insertion procedure are two separate charges … the presbyopia-correcting functionality of an IOL does not fall into the benefit category and is not covered. Any additional provider or physician services required to insert or monitor a patient receiving a presbyopia correcting IOL are also not covered … In determining the physician service charge, the physician may take into account the additional physician work and resources required for insertion, fitting and vision acuity testing of the presbyopia-correcting IOL.”
Impact of the ruling
Despite the inherent compromises, successful restoration of a patient’s desired range of uncorrected reading vision is the most dramatic and satisfying procedure performed in our profession today. As I have said several times in this column when discussing presbyopia correction, these patients feel whole again, having regained what they typically consider their full range of normal vision. The majority of our colleagues have not yet performed presbyopia correction and thus have no firsthand appreciation of just how strongly a satisfied patient responds to this procedure and to the surgeon.
At this juncture, cataract patients, not refractive lens exchange patients, are the most likely candidates for presbyopia correction. In my view, this will remain so for at least the next decade, if not longer, until we have a fully accommodating lens without compromise that can readily satisfy the refractive lens exchange candidate who typically has more demanding visual needs. While the refractive lens exchange candidate weighs the benefits and risks of surgery or no surgery, cataract patients face a less daunting, optional addition to a procedure they already understand that they need.
It may surprise the uninitiated to learn that most cataract patients elect the presbyopia correction option if it is offered. My early presumption — that my average cataract patient of 76 years would think of reading vision restoration as something more suitable for younger patients — was off the mark. I was initially stunned as almost 70% of my cataract surgery candidates elected to have presbyopia correction at their own expense. Those who do not have it typically decline with regret, usually for financial reasons.
Cataract surgery, surgeons redefined
Now that the final hurdle to presbyopia correction has been cleared with this ruling, cataract surgery and the cataract surgeon are about to be redefined. Nonrefractive cataract surgery will continue to address the obstructive visual impairment of cataract with the understanding that the patient should expect to wear glasses, especially for reading. However, refractive cataract surgery will now be equated with restoring a complete range of vision. The uncorrected distance acuity we have come to associate with today’s state-of-the-art cataract surgery is now just the required refractive starting point upon which successful presbyopia correction can be added.
The presbyopia option will be eagerly anticipated by a significant percentage of our cataract patients. Reading vision restoration is too valuable to expect that patients will respond casually to this new opportunity. They will actively seek out those surgeons who can consistently deliver this powerful new benefit as part of their cataract surgery.
Are you ready?
The challenge is considerable and requires more than switching to a new accommodating or multifocal IOL. Highly accurate IOL calculations, astigmatism correction above 0.75 D, understanding the challenges of night driving and the optimum use of myopic defocus according to each patient’s defocus threshold are topics we have covered in this column during the past 2 years. These are just a few of the elements that comprise the nuanced art of presbyopia correction. And now this art is finally recognized by a reimbursement policy that acknowledges the value it adds to cataract surgery for patients who seek restored reading vision. Now more than ever, presbyopia correction is well worth the effort it requires.
Looking back, it seems that Ridley, Kelman, Kratz, Mazzocco and countless other innovators were leading us to presbyopia correction all along. In this sense, this ruling marks a remarkable culmination to the past 50 years. As this next phase of the IOL revolution begins in earnest, let’s remember the lessons from LASIK. Lens implant presbyopia correction stands solidly on its own merits. There is no place for the overreaching we have unfortunately seen in the past. We need to be sure to get this right for the long-term benefit of our profession and our patients.
Next month
How best to configure the uncovered charges for cataract surgery with presbyopia correction.
For Your Information:
- William F. Maloney, MD, is head of Eye Surgery Associates of Vista, Calif., and a well-known teacher of cataract and lens-based refractive surgery techniques. He can be reached at 2023 West Vista Way, Suite A, Vista, CA 92083; 760-941-1400; fax: 760-941-9643; e-mail: maloneyeye@yahoo.com. In the interest of objectivity, Dr. Maloney has no financial interest in any ophthalmic product and has no financial relationship with any ophthalmic company.