CODING


the ASC is not supplying the IOL for the case.


2. Medicare does not allow ASCs to reimburse physicians for IOLs if the IOL was supplied by the phy- sician in a cataract case. The IOL must be purchased and supplied by the ASC facility for all cata- ract cases using regular or premi- um lenses for Medicare patients.


3. When ASCs correctly purchases premium lenses for a Medicare patient’s cataract case and the surgeon wants to collect the ow- ing portion related to the use of a premium lens from the patient, a compliance issue could arise. Ophthalmologists cannot charge the patient and collect money from a Medicare patient for premium lens implants used in cataract surgeries performed at an ASC. Medicare considers this to be a fraud issue for both the ASC and the physician practice. An ASC must collect the money related to the IOL directly from the patient.


4. When an ASC charges a patient for the difference between the $150 Medicare reimburses the ASC for the IOL and the full lens cost of a premium lens, it could be a compliance issue. What an ASC charges Medicare patients for a premium lens must be handled correctly to stay out of trouble with Medicare, since it directs what an ASC can charge patients in these types of cases. ASCs need to be sure that they aren’t overcharging Medicare patients for premium lenses.


For example, if a Crystalens PC


IOL is used in a cataract case and the cost for the lens is $1,100, what the ASC charges a Medicare patient for the IOL must be carefully calculated. Keep in mind that the ASC is receiv- ing the $150 for the IOL used in the


surgery from Medicare as part of the cataract extraction CPT code, so that amount must be subtracted from the amount charged to the patient. Medi- care allows only a modest mark-up on the IOL for handling ($25-$50 maximum). Medicare does not allow patients to be charged a massive mark-up (2-3 times cost or more) on premium lenses. Following is an example of how to correctly charge a Medicare patient for a premium lens:


$1,100.00 Lens Cost


– $150.00 Medicare reimbursement for regular IOL


$950.00


+ $50.00 ASC’s cost for handling of lens (markup)


$1,000.00 Final maximum amount the ASC can charge a Medicare patient


The only extra charges separate from


the surgeon’s normal surgical fee for per- forming a cataract surgery that ophthal-


mologists can charge Medicare patients in a case involving a premium lens is for his/her professional service for adjusting the premium lens. The physician is not to be involved in any way in the lens trans- action with the patient. Since physicians can purchase and bring implants into ASC facilities for many other types of cases (i.e., breast implants, etc.), it can seem like it would not be a problem to do the same with these premium lenses. However, it is a process which must be handled differently because of the bundled payment to ASCs for the IOL in the cataract extraction CPT code for Medicare patients. Thus, ASC facilities and ophthalmology prac- tices might want to review their inter- nal processes on the use of premium lenses and be sure they are handling these cases in a compliant manner to stay out of trouble with Medicare.


Stephanie Ellis, RN, is the president of Ellis Medical Consulting Inc. in Franklin, Tennessee. Write her at SEllis@ EllisMedical.com.


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