Understanding guidelines for noncovered charges essential to performing presbyopia correction

Surgeons must provide additional services, beyond those considered to be part of routine cataract surgery, to justify noncovered charges

Issue: August 1, 2007

ByWilliam F. Maloney, MD

William F. Maloney, MD
William F. Maloney

Last year at this time in this column, Ocular Surgery News published an article imparting guidelines for handling the new noncovered charges related to presbyopia correction (“Presbyopia correction: Handling the new patient charges,” July 15, 2006 ).

Based upon questions and concerns that have arisen during the past year, this article will present an update elaborating upon these central guiding principles:

Pseudophakic presbyopia correction performed in conjunction with cataract extraction constitutes a new hybrid procedure, and the charges related to each component require different treatment. Procedures related to cataract extraction are covered services, while procedures tied to pseudophakic presbyopia correction are considered refractive surgery and are not covered.
Charges for the refractive and cataract components are treated differently but are not completely autonomous. While Medicare and other third-party payers have recently asserted that they maintain no oversight with respect to noncovered services, and further that they will not set these fees, they are concerned about the potential that charges for noncovered services could be inflated to subsidize the reimbursement for covered services, thereby constituting impermissible balance billing. This ongoing link to Medicare requires that all charges for noncovered services in a hybrid procedure be judged as reasonable by the Centers for Medicare and Medicaid Services (CMS).
Categorization of noncovered charges
1. Noncovered devices: a facility charge related to a noncovered aspect of a device, in this case the presbyopia-correcting IOL, that applies only if and when a designated presbyopia-correcting IOL is utilized.
2. Noncovered services
  1. Facility noncovered services: facility fees for refractive procedures such as the use of a laser for LASIK correction of astigmatism.
  2. Surgeon noncovered services: refractive surgery procedures and related assessments and care that are required to best achieve pseudophakic presbyopia correction. The surgical correction of astigmatism is the most notable example in this category. Other examples are additional refractive tests such as dominance testing and anisometropic assessments (if applicable). This category of noncovered charges is most important for surgeons and is the focus of this article.

Clarification

Following are elaborated guiding principles that warrant renewed emphasis and further clarification by way of clinical examples:

Surgeons are not necessarily at liberty to charge “market rates” for these services when performed in conjunction with covered cataract surgery. In a hybrid procedure in which balance billing is a concern, noncovered charges for refractive services must always be seen as reasonable by CMS. “Market rates” may exceed this threshold.
Noncovered surgeon charges apply to refractive surgery procedures (together with related assessments and care) that are both necessary and not an element of routine cataract surgery.
Appropriate noncovered surgeon charges are noncovered because they pertain to refractive procedures. They are not IOL specific and apply regardless of whether a conventional or a premium IOL is employed.
Noncovered device charges are IOL specific and apply only when a designated premium presbyopia-correcting IOL is employed regardless of any noncovered surgeon services.

$Lens-Based Refractive Surgery$

Clinical examples

Question: Aren’t my charges the same for presbyopia-correcting cataract surgery and presbyopia-correcting refractive lens exchange?

Answer: Not necessarily. Although certain ethical standards may prohibit excessive charges for refractive lens exchange, it is not subject to the same CMS “reasonableness” standard as presbyopia-correcting cataract surgery when the cataract component is covered by Medicare.

Question: What about charging the presbyopia-correcting cataract patient for:

Highly accurate biometry methods such as the IOLMaster (Carl Zeiss Meditec) or immersion A-scan?
Additional capsule polishing measures required by the multifocal IOL to curtail capsular fibrosis?
Astigmatic correction performed by locating the primary cataract incision to align it with the steep axis of the astigmatic error?

Answer: All of these are examples of modifying established elements of cataract surgery. They do not justify a noncovered service. Any procedure that is a component of routine cataract surgery is already covered regardless of any revision or alteration in the procedure or instrumentation.

Question: I use a standard form of pseudophakic monovision that roughly targets plano in one eye and –1.5 D in the other. Does this sort of monovision qualify for noncovered charges?

Answer: No. Biometry and IOL power targeting are a covered aspect of cataract surgery. Simply altering the power target in one eye without performing the dominance and anisometropic assessments essential to authentic pseudophakic monovision does not justify an additional noncovered charge.

Question: What are the noncovered surgeon charges specific to using a premium presbyopia-correcting IOL?

Answer: There are no noncovered surgeon charges solely for inserting a premium presbyopia IOL. Insertion of an IOL is an element of routine cataract surgery regardless of the implant’s properties. A noncovered device charge alone applies in this circumstance. This illustrates the important principle that device charges and surgeon charges are autonomous categories of noncovered charges.

Question: When does surgical astigmatism correction qualify for a noncovered charge?

Answer: Surgical correction of astigmatism is not always necessary because some patients have little or no astigmatism. Because a residual refractive error with a spherical equivalent of 0.5 D or greater can noticeably alter the intended outcome of pseudophakic presbyopia correction, astigmatism of 0.75 D — as measured by either manifest refraction or keratometry — is generally the accepted threshold for surgical correction when presbyopia correction is part of the surgical plan.

Both the tests employed to determine the necessity of astigmatism correction and the astigmatic surgery itself are noncovered. Naturally, only patients who actually undergo astigmatism correction should incur the charge for the surgery.

Primary guiding principles for surgeons

Surgeons must provide refractive services beyond those considered to be part of routine cataract surgery to justify any noncovered surgeon charges for presbyopia correction. These additional services must be appropriate; that is, both necessary and not a part of routine cataract surgery.

If a physician does not perform any appropriate additional work, then there are no legitimate noncovered services. This is true regardless of the IOL device employed or how well the procedure might happen to accomplish the correction of presbyopia in a particular case.

All noncovered surgeon charges must be viewed as reasonable by CMS when performed in conjunction with covered cataract surgery.

For more information:

William F. Maloney, MD, is head of Maloney Eye Center 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; 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. Dr. Maloney welcomes questions from readers but regrets that, due to time constraints and the volume of messages, a personal reply cannot be guaranteed.

Lens-based Refractive Surgery Column Mission Statement: To educate readers on all aspects of lens implant refractive surgery including presbyopia correction, refractive cataract surgery, refractive lens exchange and phakic IOLs.