In December 2005, CMS clarified that CPT codes 66985, for a secondary IOL, and 66986, for exchange of an IOL, may be used to report the insertion or replacement of presbyopia- or astigmatic-correcting lenses as well as conventional lenses. 3 However, when using these 2 codes, you can’t bill the patient for the extra expense associated with a premium lens.
Are presbyopia correcting IOLs (PC and AC) covered by Medicare?
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.
What are the different types of presbyopia-correcting intraocular lenses?
The three main types of presbyopia-correcting IOLs are multifocal IOLs, accommodating IOLs and extended depth of focus IOLs. These premium lens implants offer significant advantages over conventional monofocal IOLs by enabling clear vision at multiple distances for people with presbyopia.
Does Medicare cover presbyopia or astigmatism surgery?
● Surgical correction, eyeglasses, or contact lenses to correct presbyopia or astigmatism— Medicare doesn’t cover When a patient requests a P-C or A-C IOL instead of a conventional IOL, tell the patient before the procedure, Medicare doesn’t pay physician and facility services for insertion, adjustment, or other subsequent P-C or A-C
Does Medicare pay for cataract extraction with IOL?
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 procedure, and the payment of the cataract CPT code to ASCs includes a $150 allowance as payment for a regular IOL.
Does Medicare cover IOLs?
Medicare doesn't cover When a patient requests a P-C or A-C IOL instead of a conventional IOL, tell the patient before the procedure, Medicare doesn't pay physician and facility services for insertion, adjustment, or other subsequent P-C or A-C IOL functionality treatments.
Does Medicare cover presbyopia?
Annual examinations by an ophthalmologist or optometrist are recommended for asymptomatic diabetics. conventional IOL (one that is not presbyopia-correcting) that Medicare covers, and the surgical correction, eyeglasses, or contact lenses to correct presbyopia that Medicare does not cover.
Is CPT code V2787 covered by Medicare?
V2787 - Astigmatism correcting function of intraocular lens. Non-covered by Medicare statue.
What is a presbyopia-correcting IOL?
Multifocal intraocular lens (IOL) implants are presbyopia-correcting lenses that provide clear vision at various distances from near to far. Different multifocal lenses have different focusing properties.
Does Medicare pay for multifocal IOL?
What are the exclusions? Though Medicare will cover both laser and traditional cataract surgeries, they do not yet cover New Technology Intraocular Lenses (NTIOLS). For instance, Medicare may not cover you if you need multifocal or toric lenses, though they will cover monofocal lenses.
Are multifocal IOLs covered by insurance?
Multifocal IOLs are more expensive than traditional monofocal IOLs. Furthermore, because a multifocal IOL is considered a premium lens, it is not typically covered by insurance or Medicare.
How do I bill for premium IOLs?
If you want to indicate on your Medicare claim form that you used a premium IOL in the cataract procedure, bill the premium lenses using code V2787 for a toric astigmatism-correcting lens or code V2788 for presbyopia-correcting IOLs (CrystaLens, ReSTOR and ReZoom) with the —GY Non-Covered Modifier and/or the —GA ...
How much does Medicare reimburse for IOL?
$150Today, Medicare's standard payment for IOLs implanted in an ASC is $150. The payments for IOLs made to hospitals for services provided in the outpatient setting are blended into the overall calculation of the relevant ambulatory payment classification for cataract procedures.
Does Medicare pay for toric IOL?
The Toric IOL is Medicare approved. Medicare and most insurance companies will cover a portion of the cost of this procedure. New insurance guidelines allow the patient to pay the additional costs associated with the Premium Toric IOL because of its astigmatism correction properties.
Is presbyopia surgery covered by insurance?
Presbyopia-correcting IOLs are not considered medically necessary by insurance companies. Medicare and private health insurance typically will pay only the cost of a basic monofocal intraocular lens and accompanying cataract surgery.
How is presbyopia measured?
If you wear glasses, do the test wearing your normal DISTANCE prescription glasses. Read down the chart, one eye at a time, line by line, until you reach the line you cannot read comfortably and clearly. Look at the column on the left to find the test result. Now test your other eye and record your results.
Can presbyopia be corrected after cataract surgery?
Additionally cataract surgery can correct for presbyopia as well. When the natural lens is removed an artifical lens replaces it. The artificial lenses can have multifocal correction in them allowing for clear distance, intermediate and near vision.
When did Medicare reverse its decision to cover presbyopia?
On May 3, 2005, the Centers for Medicare & Medicaid Services (CMS) published a ruling that reversed decades of policy. 1 Previously, services were either covered or not, with no middle ground. Under the 2005 ruling, if a Medicare beneficiary wants a presbyopia-correcting intraocular lens (IOL), Medicare will pay what it would cost to restore functional vision—i.e., the fee for replacing the cataractous lens with a conventional IOL, which is currently $105—and you can bill the patient for additional costs associated with the new lenses.
Can you bill a patient for natural astigmatism?
You can directly bill the patient for the services and resources that are listed above. You also can bill the patient for the following services: Correction of the patient’s natural astigmatism with either a blade or a laser. For tracking purposes, practices may create an internal code for this noncovered procedure.
Does Medicare Part B cover presbyopia?
The CMS rulings for presbyopia- and astigmatic-correcting IOLs apply to Medicare Part B only. Medicare Advantage Plans and commercial plans may have the same coverage, or they may offer more benefits to cover the additional costs. It is imperative that you verify the coverage policy for each individual payer.
How much is the IOL for cataract surgery?
Keep in mind that the ASC is receiving 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. Medicare allows only a modest mark-up on the IOL for handling ($25-$50 maximum). Medicare does not allow patients to be charged ...
Does Medicare reimburse ASCs for premium lenses?
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 premium 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.
Can an ophthalmologist charge for cataract surgery?
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.
Can an ASC claim an IOL?
Medicare considers it to be a false claim for the ASC to submit a cataract extraction claim for which they are receiving payment for the IOL when the ASC is not supplying the IOL for the case. Medicare does not allow ASCs to reimburse physicians for IOLs if the IOL was supplied by the physician in a cataract case.
Does ASC collect money from IOL?
An ASC must collect the money related to the IOL directly from the patient. 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 ...