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Experts lend guidance on billing procedures for presbyopia correction
Two weeks after the historic ruling by CMS on presbyopia-correcting IOLs, OSN gathered a team of experts to educate their colleagues on the ruling and provide concrete information on how to bill, what to charge for, and what qualifies as a noncovered presbyopia correction.
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R.
Bruce Wallace III, MD: Correction of presbyopia is a more complex procedure
than LASIK, with many elements involved. The IOL is just one factor. The May
ruling by the Centers for Medicare and Medicaid Services, allowing patients to
pay privately for an upgrade to presbyopia-correcting IOLs implanted during
cataract surgery, should have happened many years ago. It makes so much sense
to correct not only distance vision but also near vision.
The aging baby boomers are looking for solutions to their presbyopia. Not all of them will have cataract formation, yet they will want and desire this correction opportunity.
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What we hope to present here is information on how to bill for these services, allowing us to correctly get what we deserve in terms of remuneration.
It is unfortunate that we have become soft about the fact that we are being paid much less than we deserve in some areas. Cataract surgery has taken such a hit compared to many other surgical services, including others in our own field of ophthalmology. With this ruling, it suddenly feels uncomfortable to expect more payment because we have been conditioned over time to get less.
It is justified that we charge an additional amount to the patient for the presbyopic correction that we offer. We might not have all the answers now, but it is important that we at least address the opportunity here and look for ways to implement this in our practice that are legal, ethical and fair to the patient.
Kevin, could you give us the historical background?
Kevin J. Corcoran, COE, CPC, FNAO: Over the past 2 years, I have worked with eyeonics and others, and particularly with J. Andy Corley, the chairman and chief executive officer of eyeonics, to investigate the idea of patient shared billing for presbyopic correction during cataract surgery. Initially it was eyeonics that approached CMS with the concept.
One of the seminal ideas came from an earlier discussion with Dr. Maloney. This was the concept of limbal relaxing incisions performed concurrently with cataract surgery for patients who wanted to be rid of the astigmatic correction in their post-cataract glasses. LRIs on the same day as cataract surgery are noncovered, and the patient is financially responsible.
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![Alan E. Reider [photo]](/images/commonart/reider.jpg)
That idea gave rise to the concept that billing would be in two parts on the same day — one covered by Medicare, one not covered; one paid by the payer, one paid by the patient. We then expanded that idea, with Alan Reider’s help, into a basket of refractive services that would be considered noncovered by payers. That gave us the solution from the surgeon’s angle.
What we needed then was a solution from the angle of the ASC or hospital for the upgrade from a $90 IOL, which is the current average ASC cost according to the Office of Inspector General, to a $900 deluxe IOL.
The concept evolved that these presbyopia-correcting IOLs may be thought of as a standard IOL plus a deluxe IOL. This is analogous to the sale of eyeglass frames to a patient who has a benefit of $50 but wants to buy a $200 frame. The patient pays for the $150 upgrade. The idea evolved that a patient could upgrade to a deluxe IOL. This is what we proposed to payers.
Our first efforts were in the state of Kansas with the help of John Doane, MD, and his administrator, Jim Denning. They approached a number of payers and, with some success, got them to agree to allow the surgeon to charge the patient for refractive procedures, and the ASC could charge the patient for the upgrade to a deluxe IOL. It is important to note that the health plan’s payment remained unchanged — just the same as in ordinary cases.
Through the persistent efforts of Rep. Christopher Cox, this concept of patient shared billing was recognized by the CMS ruling on May 3.
Alan E. Reider, JD: We are hoping for more guidance from CMS because questions have come up.
One thing that we must keep in mind is that, unlike the situation where physicians have been able to offer these IOLs to the refractive surgery patient, we are now dealing with the cataract surgery patient covered by Medicare. And whenever you are dealing with a cataract surgery patient covered by Medicare, you catch the interest of the federal government and, in particular, the Medicare program. They are concerned with and protective of that patient group.
Patient share billing
Mr. Reider: The Medicare program essentially prohibits balance billing for a covered and assigned Medicare service. For example, if a physician has a charge of $100 for a service, but Medicare recognizes a reasonable charge of only $50 and then pays $40, the physician is entitled only to the additional $10. The patient cannot be balance-billed for the additional amount up to the $100 charge.
Now the concern is that you do not want a surgeon to say “I had gotten $2,000 an eye for cataract surgery and now I’m only getting $695. I’m upset about that. Here’s an opportunity for me to make up the difference.”
Physicians must charge an appropriate amount for the services they perform. They cannot use this as an opportunity to subsidize what they may view as an inadequate reimbursement under the Medicare program. The same thing applies to the facility. Both must charge a reasonable amount.
Reasonable charges are the additional costs incurred by the facility as a result of using the presbyopia-correcting IOL. If the facility can document those additional costs, it is perfectly appropriate to charge the patient for them. For instance, unlike traditional IOLs for which a facility will maintain an inventory, the presbyopia-correcting IOLs require special handling and must be by overnight mail. That is a cost that may be passed on to the patient.
Dr. Wallace: So CMS is not saying it is legal to balance bill the patient. But let’s define “patient share billing,” which they are allowing.
Mr. Corcoran: Patient share billing means the duality of providing a covered service and a noncovered service at the same time and billing separately for those services, hence the notion of shared billing.
Mr. Reider: I just want to raise one point on the term “deluxe IOL.” The CMS ruling refers specifically to the “presbyopia-correcting IOL,” which is not as sexy and easy to remember as “deluxe,” but it does avoid the potential confusion with the term “new-technology IOL,” which is a separate category that was previously created by CMS.
CMS may have used this more technical terminology to make it clear that this is a noncovered component.
Mr. Corcoran: I like presbyopia-correcting IOLs as the defining term for this series of products. I think of presbyopia-correcting IOLs as the class and deluxe IOL as a term for billers to use in a similar way to a deluxe eyeglass frame.
Dr. Wallace: While the Array multifocal IOL from Advanced Medical Optics had the technology to be considered presbyopia correcting, the company did not solicit this kind of reimbursement doctrine for this lens.
The lenses we are discussing that fit under the category of presbyopia-correcting IOLs are the eyeonics Crystalens accommodative IOL, the Alcon AcrySof ReStor apodized diffractive IOL and the Advanced Medical Optics ReZoom multifocal IOL, all of which are approved by the Food and Drug Administration. The prices are $895 for ReZoom, $895 for ReStor and $825 for Crystalens. We know that these are lenses that we can discuss with patients and at the same time discuss with them the additional surgery and facility fees.
Where does monovision fit into this?
Mr. Corcoran: As Dr. Maloney has written in his OSN Lens-Based Refractive Surgery column, there is no prohibition from performing and charging for add-on procedures such as LRIs, epi-LASIK or other presbyopia-correcting procedures along with cataract surgery.
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Diagnostic testing, exam
Dr. Maloney: There are essentially three categories of costs outlined in this ruling. The first and newest category is the additional charge for a premium IOL. The second is the charge for additional surgical procedures, such as LRIs, which, incidentally, presbyopia correction makes much more necessary since all presbyopia correction starts at exact emmetropia for distance. That is the refractive ground zero upon which the presbyopia correction is added. With these new reading vision metrics, even 0.75 D of astigmatism can significantly impact the presbyopia correction.
The third category, which I would call ancillary charges, are the preoperative tests necessary to determine corneal topography and wavefront analysis, the myopic defocus threshold, pupillography and ocular dominance. Together, all of these tests determine the specific implant that will best meet the patient’s individual reading goals, as well as the overall surgical approach, such as whether astigmatic keratotomy is likely to be needed.
Mr. Corcoran: That is correct, and I would add to that a fair amount of tender loving care. There is a longer postoperative care period and the implied promise that the surgeon will make every effort to make the patient independent of glasses.
Paul N. Arnold, MD, FACS: It seems to me that there is another way to bill for surgeon services — an additional charge for the presbyopia-correcting exam. If we have a patient seeking presbyopia correction we would charge for physician services in the office, first of all using eye exam codes, but in addition would charge for a presbyopia or refractive exam and counseling. This is a charge that would not be tacked on to the surgeon’s surgical fee but would be a physician service provided in the office. Is that a reasonable way to think about it?
Mr. Corcoran: I struggle with that one. The idea of two exams on the same day by the same physician on the same patient is troublesome for me.
Dr. Arnold: One element is the medical examination, and the other element is the refractive evaluation and counseling.
Mr. Corcoran: Perhaps a way to think about is that the exam is paid by Medicare and the refraction is paid by the patient. And this particular refraction, as Dr. Maloney mentioned, might be accompanied by topography, wavefront aberration, pachymetry or perhaps contact lens fitting if this happened to be a patient with a previous LASIK.
Presbyopic counseling
Dr. Wallace: What about the presbyopic counseling Paul mentioned? Should that be a separate item?
Mr. Reider: I cannot address those issues adequately because I am not as comfortable with the clinical issues. If I were analyzing this, the way I would do it is as follows.
It should be clear now what services go into the provision of a normal cataract extraction and IOL implant. You all have protocols and services you perform on a routine basis in connection with these services on behalf of Medicare patients and, for that matter, any patient.
To the extent that you do something differently, something additional that you would never do for a routine cataract implant, and this is something you should appropriately do in connection with the implantation of a presbyopia-correcting IOL, then that is a noncovered service for which you may bill the patient directly.
What I am hearing here is that in the course of the traditional preoperative evaluation you may expand the discussion to include an additional option that previously had not been available to the Medicare patient, and that is the availability of presbyopia-correcting IOLs. That would presumably require additional time with the patient. Instinctively, I would say it takes more time, but I also understand Kevin’s point that perhaps there we are trying to split hairs too finely.
Dr. Maloney: It became clear to me early on that we needed to be specific in our description of additional presbyopia-related services.
We present to a patient the list of tests that are necessary to best treat their presbyopia, many of which I listed earlier. Each test, along with its results and interpretation, are documented in the medical record.
Mr. Corcoran: I would endorse the idea that when you can point to a task, you are probably on more solid footing than if you simply say my informed consent for this patient takes X minutes. You are on soft ground if the dialogue with patients or the time you take with them turns into the notion of “pay me by the hour.”
Dr. Arnold: One of the ideas behind the notion of charging for a presbyopia exam and counseling session is, for example, Bill’s basket of tests. Say there are 10 tests on his list, and those are things that we do and document and interpret that are precursors to the counseling that is required thereafter.
Mr. Corcoran: Then perhaps we can say that the tests consist of measurements as well as interpretation, and your charge includes them both. You could estimate the expected amount of time for the counseling as part of the cognitive portion of the test.
Dr. Maloney: Listing specific tests and then the interpretation of those tests, which is a component of the discussion with the patient, makes great sense to me.
Dr. Arnold: So it seems to me you have the choice of either charging for all of those tests a la carte or bundling them together in a “presbyopia exam” and/or “presbyopia counseling session.”
Mr. Corcoran: I would extend that idea to include the entire basket of services — some diagnostic, some surgical. I do this for the simple reason that, if the patient says, “I like this idea, how much is it?” you have an answer other than, “Well, the only thing I can tell you is that it is going to be a lot of money, but I cannot tell you exactly how much.” If you use that approach, few patients will sign up.
If you can conceptualize a basket of services and the duration of time to care for the patient, then the patient can accept that.
Pricing
Dr. Maloney: In my experience, a single, supplemental, optional global fee for presbyopia correction is essential.
Mr. Reider: If you go that route, I would caution you to make sure you can justify the fee based on the appropriate charge of each package component should there be any inquiry into the propriety of your fee.
Dr. Maloney: Yes. The global fee is the sum total of each component of presbyopia correction: additional surgical fees, ancillary fees and premium IOL fees when a premium IOL is used. Clearly there will be no additional premium IOL fee in those cases when a conventional IOL is used for the presbyopia correction.
But what can we tell surgeons to guide them on whether their charge for each of these additional services is reasonable?
Mr. Corcoran: Alan’s caution is striking. If your normal charge for limbal relaxing incisions (LRIs) is $500, but in regard to presbyopia correction it is $1,500, somebody will argue sooner or later that the disparity represents a form of gouging, and its sole purpose is to balance-bill the patient. A disconnect of that magnitude is easily identifiable.
Mr. Reider: That is the problem. Anything you do in connection with the implantation of a presbyopia-correcting IOL is presumably something you have already done, for which you have charged the patient. There is probably a fee schedule of some kind in your office.
Dr. Maloney: I get a strong sense that we need some initial guidelines that are specific enough for physicians to feel comfortable with.
For instance, we used the fee of $450 for astigmatic keratotomy, in the rare cases that Medicare pays for its use. That is something concrete.
Mr. Corcoran: This can happen if a surgeon realizes the charges must be reasonable. For instance, a refraction cannot go from $20 to $200 or LRIs from $450 to $1,400.
Non-Medicare insurance
Dr. Wallace: Should surgeons check on an individual basis with their private insurance carriers to see whether they allow us to bill these patients separately?
Mr. Corcoran: We think they should. We also believe that the number of people making this inquiry will be so large that third party payers will simply tire of it and will follow or copy Medicare’s approach. It will just take time.
Dr. Wallace: Will we have to file a separate Advanced Beneficiary Notice (ABN) to Medicare in order to file the necessary paperwork involved in receiving money from Medicare.
Mr. Corcoran: The ABN is a means of asking the patient to be financially responsible for something that you expect Medicare might not cover. Medicare occasionally will pay for LRIs, so an ABN is needed.
Dr. Wallace: This is really for all Medicare LRIs then.
Mr. Corcoran: Yes.
Dr. Arnold: The only other case would be for surgically induced astigmatism. If the patient has not had previous surgery, astigmatic keratotomy or LRIs will not be covered.
Mr. Corcoran: In fact, last year, of the 1.7 million Medicare beneficiaries who underwent cataract surgery, Medicare paid for 3,300 LRIs. So, for the vast majority of cases, LRIs will not be covered by Medicare, thus the reason for an ABN.
Mr. Reider: But that is an exception. It is a covered procedure, but only in limited circumstances. For the most part, the other services we are talking about here are never covered.
Mr. Corcoran: Topography, if you had a prior corneal insult or trauma, might be covered. Again, it is rare.
Mr. Reider: The way CMS has drafted its policy, it seems to me that they are saying, “Look, we are dividing a line here. The part of this that we are paying for is the covered service, and everything else that falls on the other side is a noncovered service.” An ABN is not required for a noncovered service.
It is wise and necessary to inform the patient, strictly within your office environment, of the noncovered charges. So, as a practical matter, you need some form to document this. I am speaking in regard to intra-office patient relations here, not with regard to Medicare or other payers.
Coding and billing
Dr. Arnold: The facility will charge, of course, the basic facility charge for 66984 plus some additional charge for the presbyopia-correcting IOL. But what about the surgery itself and the surgeon’s charge? Other than some additional surgery like AK, we are not actually doing anything physically different during the operation itself to be able to charge anything additional. What do you think about that?
Mr. Corcoran: You are right. The idea of a basket of additional services includes LRIs and diagnostic tests, and it is a distinct package. However, the cataract procedure is the same.
The claim for 66984 or 66982 remains as it always was. But the other set of services that Dr. Maloney and Mr. Reider spoke about is not covered.
To codify those services on a claim form, we have picked an HCPCS [Healthcare Common Procedure Coding System] code that states that these are services that are not medically necessary. The code is S9986. It is a code to help identify and enumerate charges on the financial ledger and CMS-1500. As you give informed consent, you can say to the patient, “Standard surgery is this much, and a more enhanced or upgraded procedure is that much, and here is the difference between those two.” (See figure.)
Dr. Wallace: As Bill has pointed out in his column, IOL calculations, accuracy, astigmatic control, these are all elements that go into the mix. We are calling attention to this by asking patients to pay more for this service. So it puts us, as surgeons, in a different light when it comes to cataract surgery. The patient is going to expect great results. There will be a learning process to determine the percentage of patients who will be candidates for presbyopia-correcting IOLs.
Dr. Maloney: Bruce, you are touching on what may be our greatest challenge here. That is, as a group of professionals, we must not rush into this and overreach. Presbyopia correction is one of the more remarkable and certainly, in terms of the patient’s responses, more impactful procedures that we do. It can stand on its own merits provided it is done properly.
This means understanding that successful presbyopia correction requires much more than just reaching for a deluxe IOL. As we approach this next phase of the IOL revolution, I must admit to being somewhat concerned that there could be a repeat of the mistakes we made with LASIK.
So I would like to remind readers to remember the lessons of LASIK. We have been backpedaling for the past decade when it comes to LASIK. I hope that as a profession we have learned enough not to let that happen again with presbyopia correction.
Dr. Arnold: In the past 40 years of Medicare’s existence there have been two radical changes that have hit cataract surgeons. The first was the resource-based relative value scale, which hit us in the early 1990s and sent cataract surgeons on a downward slide, driving some of us into early retirement. The more resourceful of us brought in non-Medicare-dependent surgeries to keep our practices successful.
This new CMS ruling is the second radical change that has occurred in Medicare. This ruling affects cataract surgeons and opens the door to bringing us back into the marketplace to take care of Medicare patients.
For Your Information:
- R. Bruce Wallace III, MD, can be reached at 4110 Parliament Drive, Alexandria, LA 71303; 318-448-4488; fax: 318-448-9731; e-mail: rbw123@aol.com. Dr. Wallace is a consultant for AMO. He has no financial interest in the products mentioned in this article.
- Kevin J. Corcoran, COE, CPC, FNAO, can be reached at Corcoran Consulting Group, 1845 Business Center Drive, Suite 108, San Bernardino, CA 92408; 800-399-6565; 909-890-1333; kcorcoran@corcoranccg.com.
- Alan E. Reider, JD, can be reached at Arent Fox PLLC, 1050 Connecticut Ave. NW, Washington, DC 20036; 202-857-6462; fax: 202-857-6395; e-mail: Reider.alan@ArentFox.com; ReiderA@ArentFox.com.
- 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.Paul N. Arnold, MD, can be reached at Arnold Vision, 1011 E. Montclair, Springfield, MO 65807; e-mail: pnarnold@arnoldvision.com.