Are you sure if you’re billing for PC IOL cataract cases accurately? If not, try considering it as
it’s very necessary for Ophthalmology billing procedures! When your facility’s Medicare patient
requests a Presbyopia-correcting instead of regular lens, special rules are to be followed to stay
in compliance with Medicare guidelines. It becomes a compliance problem if guidelines are not
carried or followed accurately. Ensure these cases are perfectly handled by the team or staff at the
office.
Accurate Ophthalmology billing:
Medicare doesn’t reimburse more than the usual. It is the same as regular IOLs for the cases that
include the usual payments for the cataract extraction procedure codes 66984, 66982 etc. Healthcare
professionals must include and indicate the same on the claim form about the usage of PC IOL in the
case.
Healthcare professionals must bill these special IOLs using V2788 for the PC IOL.
It’s recommended to append GY, the non-covered modifier or GA modifier to the V-code in order to
indicate patient signed Advanced Beneficiary Notice from the waiver.
While it’s not compulsory to have patient signed Advanced Beneficiary Notice, it’s a better option
to avoid misunderstanding with patients on their own portion as PC IOLs will never be covered by
Medicare.
Crysta lens is a PC IOL added to the Medicare list of NTIOL which was billed with code Q1003 ten
years back.
Medicare and Reimbursement:
Ophthalmology billing procedures are unique and when healthcare professionals bill Cataract
Extraction Codes with Medicare, they have to understand the importance of inserting IOL in the
procedure and also the payment for the Cataract code involves the allowance for payments of regular
posterior chamber or anterior chamber IOL.
Though it’s considered as different type of IOL, the reimbursement is being received for the
placement of an IOL. It doesn’t change if you have been paid for an IOL by Medicare.
Compliance issues for Ophthalmology billing:
If the healthcare providers or surgeons decide to purchase the PC IOL for the case and apparently
bring it to ASC for the case, then it becomes a compliance issue.
The reason is that Medicare does not permit ASC to bill for the Cataract with placement of an IOL
along with the -52 Reduced Services. Modifiers also don’t allow any other billing method to convey
to that the ASC did not supply the IOL and so, it will not be reimbursed for the IOL supply.
As there aren’t any provisions to allow ASC for breaking the implant portion of the procedure from
the Cataract extraction, Medicare needs ASC to always purchase IOL for all these cataract cases.
It becomes an invalid or false claim for Ophthalmology billing as Medicare doesn’t allow ASC to
submit cataract extraction claims for which healthcare professionals are being reimbursed for the
same IOL when ASC didn’t purchase or supply the IOL.
Medicare also doesn’t support ASC payments for IOLs to healthcare professionals, also if IOL is
purchased by the practitioners in like these situations for ophthalmology billing.
IOL should be purchased and supplied by ASC facility for these cases.
Beyond that in ophthalmology billing, the charges for the use of PC IOLs become another compliance
issue because the charges must be according to the Medicare directions for these cases.
Overcharging the patients for these lenses are strictly condemned and can also be a compliance
issue. Healthcare professionals must be aware of compliance issues due to overcharging patients for
PC lenses.
As healthcare professionals are allowed to bring many implants for other different cases, it might
seem right to follow the same for the cataract extraction procedures PC IOLs. Well, it needs to be
handled in a different way due to bundled payments for IOL in cataract extraction CPT codes.
New Technology Lenses:
Generally, Medicare won’t allow payments for IOLs as a supply that’s billed separately in the claim
form. It’s actually included in ASC facility fee reimbursed for the cataract extraction procedures
CPT codes.
As it’s well known that facility will be charging parents for the difference, Medicare advises
strongly to have Advanced Beneficiary Notice signed by patients.
It can also be a rare circumstance to use these special lenses. New technology IOLs should actually
reimburse to maximum by Medicare when properly and perfectly billed.
Better to always review the State’s Medicare coverage and guidelines and check with insurance
companies if regular IOL lenses for patients apart from Medicare are possible.
What are the difficult cataracts in Ophthalmology billing procedures?
CPT came out with different solution twenty years back. It came out with new procedure code for
differentiating the usual cataract procedures from patients with special problems.
These problems are the ones which make the procedure stricter and difficult, taking a huge risk by
involving surgeons with unusual techniques. It was important to use the code 66982 to bill difficult
procedures.
The complex extraction procedures involve devices for unusual techniques, those are:
Iris Expansion Device
Pupil Stretcher
Use of a Capsular Ring in the procedure
Use of Dye in the procedure
Suture Support for the IOL or
Primary Posterior Capsulorhexis
The patient population likely have “Difficult” Cataracts usually includes:
Pediatric patients (under age 8)
Performed on patients in the Amblyogenic Developmental Stage
Patients with weakened or absent lens support structures, usually resulting from:
Glaucoma (code section 365)
Small pupils (code 379.40)
Subluxated lens
Pseudoexfoliation
Trauma
Marfan Syndrome
Uveitis
Male patients taking Flomax
Hope you got the information on Ophthalmology billing procedures. For more suggestions, please
comment below, we will definitely consider them if relevant. For more queries and updates on
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https://qwayhealthcare.com/blog/5-key-points-in-ophthalmology-billing/