CODING
How to Correctly Code and Bill for Premium IOLs Watch out for these potential problem areas BY STEPHANIE ELLIS, RN
Several compliance issues could come up with the use of intraocular lenses (IOL) used in cataract cases performed on Medi-
care patients in ASCs. These compli- ance issues involve the use of premium lenses. When a Medicare patient has a presbyopia-correcting (PC) IOL or an astigmatism correcting (AC) IOL inserted instead of a regular IOL, there are special guidelines which must be followed by ASCs and ophthalmology practices to stay in compliance with Medicare guidelines.
Billing Correctly First, even though Medicare does not reimburse ASCs any more for the use of premium lenses in their cataract cases than they do for regular IOLs, the ASC still needs to indicate on their Medicare claim form that a pre- mium lens was used in the case. Bill the premium lenses using the V2788 code for PC IOLs or the V2787 code for an AC IOL. Append the -GY Non-Covered Modifier and/or the -GA Modifier to the V-code to indi- cate that you don’t expect payment for the IOL and that you have had the patient sign an Advanced Bene- ficiary Notice (ABN form or waiver) and that the patient understands he/ she will have the remainder amount owing for the use of the special premium lens as an out-of-pocket expense. While it is not mandatory to have the patient sign an ABN, since the PC and AC IOLs are never cov- ered by Medicare, it is a good idea so that there will be no misunderstand- ings with Medicare patients of his/ her owing portion.
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Medicare Reimbursement to ASCs for IOLs When ASCs bill the 66984, 66982 or other cataract extraction procedure code to Medicare, those codes include the insertion of an IOL in the cataract pro- cedure, and the payment of the cata- ract CPT code to ASCs includes a $150 allowance as payment for a regular IOL. That does not change when premium lenses are used in the case. ASC facilities are still being reimbursed for the place- ment of an IOL in the cataract procedure.
Compliance Issues Involved with Using Premium Lenses Following are the areas where com- pliance issues come up with these types of cases: 1. When the surgeon wants to pur- chase the premium lens for the case and bring it into the ASC for
use in the case, it is a compliance issue. Medicare does not allow ASCs to bill for cataract extrac- tion procedures with placement of an IOL with the -52 Reduced Services Modifier or using any other billing method to convey to Medicare that the ASC did not supply the IOL and, there- fore, should not be reimbursed for the IOL supply. Since there is no provision to allow the ASC to break out the implant portion of the procedure from the cataract surgery itself, Medicare requires that the ASC facility must supply the IOL for all Medicare cata- ract cases. Medicare considers it to be a false claim for the ASC to submit a cataract extraction claim for which they are receiv- ing payment for the IOL when
The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion.
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