Q: What is the status of reimbursement for presybyopia-correcting intraocular lenses?
A: A presbyopia-correcting intraocular lens is intended for the visual correction of aphakia in adult patients in whom a cataractous lens has been removed, and who desire increased spectacle independence with near and distance vision. This innovative technology is quite different from a conventional IOL that restores visual acuity just for distance.
There are three different presbyopia-correcting IOLs presently on the market: the Crystalens by Eyeonics; the AcrySof ReStor apodized diffractive optic posterior chamber IOL by Alcon; and the ReZoom by Advanced Medical Optics. Though the desired outcome is the same for the three lenses, each employs a different design.
Q: What are the indications for the use of such a lens in place of a traditional IOL?
A: The commonly accepted indications for cataract surgery include:
• objective evidence of a cataract;
• reduced Snellen visual acuity;
• lifestyle complaints;
• good prognosis for improvement;
• the patient can tolerate the procedure; and
• the patient desires surgery.
Many local medical review policies (LMRPs) or local coverage decisions (LCDs) include specific visual acuity or other requirements. For carrier-specific information, check your local carrier website.
The optimal candidate for these lenses is also motivated by an aversion to eyeglasses, particularly reading glasses. Typically, this patient has much in common with the candidate for refractive surgery with high expectations and lower tolerance for inaccuracy and missed targets. This creates additional challenges for the surgeon.
Q: May a patient who does not meet the criteria for cataract surgery still have presbyopia correction with one of the new IOLs?
A: Yes, however the patient will have to pay for the entire procedure (surgeon and facility). With few exceptions, third party payers do not cover cosmetic refractive procedures.
Q: Do additional charges apply for cataract surgery with the new IOLs?
A: The basic charges of the surgeon and hospital or ASC for standard cataract surgery remain the same. Additional services related to presbyopia correction include diagnostic tests (i.e., corneal topography, pachymetry, wavefront aberration testing), refractive keratoplasty, and the upgrade to a deluxe IOL.
Q: Does Medicare allow patients to choose a presbyopia-correcting IOL and pay the additional charges?
A: Yes. On May 10, 2005, the Centers for Medicare & Medicaid Services published Ruling No. 05-01 clarifying payment rules providing access to these IOLs for Medicare beneficiaries. The ruling effective date was May 3, 2005.
The ruling provides guidance on what may be charged to the patient. It states, "… The beneficiary is responsible for payment of that portion of the facility charge that exceeds the facility charge for insertion of a conventional IOL following cataract surgery. … The beneficiary is responsible for payment of physician services attributable to the non-covered functionality of a presbyopia-correcting IOL … the physician may take into account the additional physician work and resources required for insertion, fitting, and vision acuity testing of the presbyopia-correcting IOL compared to insertion of a conventional IOL."
The complete ruling is available at http://www.cms.hhs.gov/rulings/.
Q: Do other third-party payers share Medicare's point of view?
A: Some do. Where the third-party payer bundles presbyopia correction with standard cataract surgery, providers are disinclined to offer these deluxe IOLs and the associated services. Encourage your patients to ask their health plan for a favorable policy more in line with Medicare's approach.
Q: How do I explain the charges to patients?
A: Because patients are deeply concerned about their financial obligations, it is helpful to break down the fees in a readily understandable fashion. A solitary all-inclusive number does not segregate the charges that will be reimbursed by insurance from the non-covered fees, and raises the specter of balance billing violations. Most importantly, the patient wants to know what he owes. Your office should take the opportunity to collect payment for the non-covered items and services in advance of the procedure.
Q: What type of documentation is required to support the financial arrangements associated with this surgery?
A: Other than the usual medical records, there are important documents required to address the economic considerations of cataract surgery with presbyopia-correcting IOLs. Patients must be notified in advance of financial responsibility, and agree to pay for the non-covered services. The financial agreement with the patient must delineate covered and non-covered services and the amount of the patient's financial responsibility.
For Medicare beneficiaries, an Advance Beneficiary Notice serves this objective. Your office and the hospital or ASC must each get an ABN signed by the patient. While the ABN is formal, it is abbreviated and a more expansive notice may be helpful.
For non-Medicare beneficiaries, there is an important additional requirement. Your office and the hospital or ASC must seek permission, prior to surgery, from the third party payer to bill beneficiaries for presbyopia correction and a deluxe IOL as non-covered services. Also, prior to surgery, the patient must agree to pay for the additional services and the upgrade to a deluxe IOL under the principle of patient-shared billing.
Ms. McCune is vice president at Corcoran Consulting Group. Contact her at email@example.com or 1 (800) 399-6565.