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Making the Most of Premium IOLs:Your guide to medical coding

and compliance.

John Rumpakis, OD, MBA


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Making the most of premium IOLs

What Are You Waiting For?The excitement surrounding the premium IOLs is growing within the ophthalmological and optometric professions, yet there remains great confusion about many aspects of the procedure and process. Why all of the excitement? After all, isn’t this just another surgical procedure and if so, why should optometry be involved, much less excited? Isn’t this exclusively the territory of ophthalmology? While the surgical procedure itself is confined to ophthalmology, the primary driver of the patient selection and market is optometry – more specifically you!

Just as in the refractive surgery market – optometry has a significant opportunity waiting to be developed. Co-managing a cataract patient today is much more involved and rewarding process than it has been in years. With the advent of the Premium Intraocular Lens category (both for presbyopia in 2005 and astigmatism in 2007), patient choices are much broader and the ability to provide excellent surgical corrective solutions abound.

Let’s revisit a little history. On May 3, 2005, Medicare set forth policy concerning the requirements for determining payment for insertion of presbyopia correcting intraocular lenses (PCIOLs) following cataract surgery (http://www. cms.hhs.gov/Rulings/downloads/CMSR0501.pdf). This ruling from the Centers for Medicare & Medicaid Services, which allows surgeons to bill the patient for the extra costs involved in implanting these lenses was certainly unprecedented, revolutionary, and unexpected in the ophthalmic area. This CMS policy created a new market within optometry and ophthalmology, specifically for patients aged 50 years and older. This specific market demographic was and continues to experience tremendous growth. The 50+ market is expected to grow seven times faster than any other segment during the next 15 years while the volume of refractive surgical candidates have decreased or are flat because baby boomers have reached their 50’s. Although 50-something’s may not make good refractive surgery candidates they certainly are candidates for a presbyopia correcting IOL following cataract surgery.

Subsequent to this, on January 22, 2007, Medicare set forth policy concerning the requirements for determining payment for insertion of astigmatism-correcting intraocular lenses (ACIOLs) following cataract surgery (http://www.cms.hhs.gov/Rulings/downloads/CMS1536R.pdf).

These recent Medicare rulings concerning presbyopic and astigmatic correcting IOLs are a huge win for cataract surgery patients and physicians alike. Before this ruling, Medicare patients who needed cataract surgery

were denied access to technology such as an approved multifocal IOL like AcrySof® ReSTOR® IQ IOL or the AcrySof® IQ Toric lenses for astigmatism. Furthermore, any extra tests and work specifically related to the correction of either presbyopia or astigmatism are not covered and need to be charged directly to the patient as an out-of-pocket fee. This also represented a change in policy and procedure. Rather than send a claim directly to Medicare for payment, both optometrists and ophthalmologists must bill patients directly for these services and the non-covered component of the IOL itself, which in and of itself requires even greater communication and coordination between these two groups to achieve the best outcomes that this technology can deliver. These CMS rulings essentially removed the balance-billing obstacle by establishing that all charges, either by physician or facility, for additional items and services intended to correct presbyopia or astigmatism are non-covered services. Consequently, collecting for non-covered services from the patient doesn’t constitute balance billing and e!ectively removes the intrinsic obstacles contained within the process.

As a result, Medicare beneficiaries may upgrade from a conventional monofocal IOL to either a PCIOL or ACIOL, as long as they request the additional products/services and are willing to pay all charges beyond those associated with standard cataract surgery. To the extent that Medicare patients are willing to pay the extra costs for a PCIOL or ACIOL, facilities and physicians may receive an additional payment from the patient than that amount allowed by Medicare for insertion of a conventional IOL following cataract removal. Prior to the May 2005 ruling, Medicare o"cials understood that the new IOL technology was a technology that patients were interested in receiving and the rules in place at that time were an obstacle to good patient care. As long as providers and patients have an honest discussion about the pros and cons of the lenses and the cost and coverage di!erences between conventional and these premium IOLs, it creates a win-win situation for all concerned. This decision represented an important new beginning for Medicare policy, moving us in the direction of technological advance, individual choice, and patient supremacy over bureaucracy.

New Market/New Procedures/New Thought ProcessTo understand how physicians and practices can most appropriately incorporate this new technology into their patient o!erings, a fundamental understanding of the current process is critical– because this will not be done without scrutiny of the federal government’s oversight

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o"ce – the O"ce Of Inspector General (OIG). M.D.’s and O.D.’s alike who are going to be providing the pre-, intra-, and post-surgical care must have the knowledge to understand the di!erences between conventional IOL implantation and PCIOL implantation so that they can avoid the pitfalls from inappropriate billing policies and maximize the benefit of incorporating refractive IOLs into their practice.

Doing It Right – Traditional Monofocal ImplantationVisual Tests Prior to Cataract SurgeryIn most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the intraocular lens are su"cient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used (See example below). For patients with a dense cataract, an ultrasound B-scan may be used. Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical necessity for the additional tests is fully documented.

Transfer of Care Between ProvidersOrdinarily, the global surgery fee schedule allowance includes preoperative evaluation and management services rendered the day of or the day before surgery, the surgical procedure, and the post-operative care services within the defined post-operative period. Post-operative care may be rendered by an ophthalmologist, optometrist, or providers who are licensed to render such services. When a physician transfers the care of a patient to another provider outside their group practice within the global period, it is consid-

Dates of servicefrom

Dates of service

to

Place of service

Type of service

Procedures, services, supplies (explain unusual circumstances)

CPT-HCPCS - Modifier

Diagnosis code

Charges Days or units

1 2/25/2010 11 92004 1 XXX.XX 12 2/25/2010 11 92015 2 XXX.XX 13 2/26/2010 11 76519-26-50 1 XXX.XX 2

Diagnosis: 366.16, Nuclear Sclerosis (O.D. or M.D.)

ered “a transfer of care”. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance. Each provider must agree and document the transfer of care in the medical record. The agreement must be in the form of a letter or written as a notation in the discharge summary/hospital records or Am-bulatory Surgical Center records. The appropriate CPT®-4 modifiers must be added to the surgical procedure code:

• -54 Surgical care only• -55 Post-operative management only• - 79 Unrelated Procedure or Service by the Same Physician

During the Post-operative Period

The claim for the surgical care only and the claim for the post-operative care only must identify the same surgical date of service and the same surgical procedure code. Modifier 54 must be reported with the surgical care only. For claims where physicians share post-operative care, the assumed and/or relinquished dates of care must be indi-cated in Item 19 of the CMS-1500 claim form, or electronic media claim equivalent. Where a transfer of post-operative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service. Once the physician has seen the patient, that physician may bill for the service. When more than one physician bills for the post-operative care, the post-

operative percentage is apportioned based on the number of days each physician was responsible for the patient’s care. The maximum percentage for post-operative care for 66984 is 20 percent, and the length of the associ-ated global period is 90 days. Generally, the diagnosis for cataract is the most appropriate (366.XX) to use, but many carriers will also accept pseudophakia (V43.1) code for the post-operative portion of care.


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Billing It Right – Traditional Monofocal Implantation

Example: Billing for 1st Eye Dr. Jones performs procedure code 66984 on March 1st and cares for the patient through March 2nd. Dr. Smith assumes responsibility for the patient on March 3rd for the remainder of the global period.

Dr. Jones’ claim contains the following:

03/01/2010 66984 5403/01/2010 66984 55 assumed 03022010 relinquished 03022010


Dates of service

to

Place of service

Type of service



Diagnosis code


1 3/1/2010 11 66984-54-RT 1 XXX.XX 12 3/1/2010 11 66984-55 RT 1 XXX.XX 1


Dates of service

to

Place of service

Type of service



Diagnosis code


1 3/1/2010 11 66984-55-RT 1 XXX.XX 1

Surgeonbilling

CPT codeused

ICD-9 codeused

Typicalcharges

Coverage

Line 1Line 2

66984-54-(RT/LT)66984-55-(RT/LT)

366.16Nuclear Cataract

$800.00* Send to carrier as traditionally billed

Optometristbilling

CPT codeused

ICD-9 codeused

Typicalcharges

Coverage

Line 1 66984-55-(RT/LT) 366.16 (Nuclear Cataract) or V43.1

(Pseudophakia)

Maximum of 20% of surgeon’s fee. Based upon portion of global post-operative care

provided.

Send to carrier as traditionally billed

Diagnosis: 366.16, Nuclear Sclerosis (Surgeon’s Billing)

Diagnosis: 366.16, Nuclear Sclerosis (O.D. Post-Operative Portions)

Format of typical charges surrounding the patient with cataracts with conventional IOL implantation & Co-management

Dr. Smith’s claim contains the following:03/01/2010 66984 55 assumed 03032010 relinquished 05302010

Traditional Billing Process For Monofocal IOL Implantation & Co-Management


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Current Coding Guidelines For IOL Implantation &Co-Management For A Patient Who Is Upgrading To A Premium IOL

Authors Note - The following claim form examples are for a Presbyopic-Correcting IOL (PCIOL), however the same protocol would follow for an Astigmatic correcting IOL (ACIOL) by substituting V2787 – Astigmatism Correcting Function of Intraocular Lens in place of V2788 - Presbyopia Correcting Function of Intraocular lens. Additionally, the diagnosis of Astigmatism 367.2X (5th digit dependent on specific type of Astigmatism) would be used in place of the diagnosis of Presbyopia 367.4

Picking The Right Surgical CodeThe code for standard cataract surgery fees is CPT code 66984, and it is recommended that physician’s o"ces use this code when billing Medicare or commercial insurance when a patient elects a PCIOL. CPT code 66984 is for the covered portion of the surgery and IOL. That part of the process should be billed in standard fashion. For the non-covered upgrade, code V2788 should be used to describe the upgrade to a PCIOL. It is also advised that surgeons should not use CPT 66982 (complex cataract) when implanting presbyopia-correcting IOLs, unless the require-ments of code 66982, as defined in the CPT, are also met or physicians receive specific instructions from CMS that state that this is acceptable.

Since the OIG will be watching for patterns of abuse with the advent of this new policy, surgeons and O.D.’s alike should be careful not to change patterns of recommend-ing cataract surgery to their patients. Moreover, surgeons may not require patients to elect a PCIOL as a condition of implanting an IOL; the patient must always have the op-tion of selecting a conventional monofocal IOL. Charging The PatientThe beneficiary is responsible for paying for the portion of the physician’s charge for the PCIOL that exceeds the physician’s charge for a conventional IOL. There are many non-covered technical work expenses associated with the preoperative process of presbyopic cataract surgery and many additional non-covered work expenditures associat-ed with the post-operative care, which is necessary in order for patients to achieve satisfactory near, intermediate, and distance vision.

While most anticipate that residual refractive error will be corrected with additional surgery, keep in mind that the existing covered Medicare benefit of one pair of spectacle lenses, an ophthalmic frame, or one pair of contact lenses per surgery remains intact even for the patient who re-quested the upgrade to a PCIOL procedure/product.

Using An Advance Beneficiary Notice (ABN) or Notice Of Exclusion From Medicare Benefits (NEMB)Since these additional tests are not covered by a carrier, and the patient will most likely be bearing 100% of the ad-ditional non-covered cost, there are strict rules of notifica-tion that must be followed before performing and billing the tests. Practices should have a patient sign a waiver and keep it with his chart. It is critical that all the specifics of the elective part of the procedure need to be detailed in this waiver to be given to and signed by the patient. The waiver should clearly define what Medicare pays for and for what the patient is financially responsible. The most appropriate document for this purpose is NOT the Advance Beneficiary Notice as is commonly used in day-to-day practice, but is the CMS document called the Notice of Exclusions From Medicare Benefits (NEMB) form http://www.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf . While this form is not required, it’s use is “strongly encour-aged” by CMS. This form is not to be sent to Medicare; its purpose is for documentation only and should remain in the patient’s file.

Visual Tests Prior to Cataract SurgeryJust as in conventional or traditional monofocal implanta-tion surgery, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the in-traocular lens will be covered by Medicare where the only diagnosis is cataract(s).

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However, when the patient requests an upgrade to a PCIOL, there are additional tests, both pre- and post- op-eratively, that, if medically necessary, may be billed directly to the patient as they are deemed non-covered services. The typical set of additional tests performed, in addition to the comprehensive examination and A-scan could include:• Initial Consult (separate from Comprehensive Exam)• Dry eye evaluation and treatment• Corneal topography• Wavefront aberration testing• Pachymetry• Additional A-scan & Lenstar or IOLMaster• Contact lens trial fitting• Additional refractions, post-operative evaluations and

progress evaluations to deal with residual refractive error• Refractive surgical procedures for the purpose of reduc-

ing dependence on eyeglasses or contact lenses (e.g., limbal relaxing incisions, corneal relaxing incisions, LASIK, etc.).

These additional tests and care protocols may be itemized to the patient or globally grouped into a PCIOL package of services which is directly billed to the patient. Keep in mind, however, that the surgeon, the O.D., and most im-portantly, the patient must have a clear understanding of the additional services performed, who’s performing them, and what the associated cost will be prior to them being provided.


Dates of service

to

Place of service

Type of service



Diagnosis code


1 2/25/2010 11 92004 1 XXX.XX 12 2/25/2010 11 92015 2 XXX.XX 13 2/26/2010 11 76519-26-50 1 XXX.XX 2

Diagnosis: 366.16, Nuclear Sclerosis (O.D. or M.D.)

Transfer of Care Between ProvidersJust as with traditional monofocal implantation surgery, the global surgery fee schedule allowance includes preop-erative evaluation and management services rendered the day of or the day before surgery, the surgical procedure, and the post-operative care services within the defined post-operative period. Post-operative care may be rendered by an ophthalmologist, optometrist, or providers who are licensed to render such services and all of the same guide-lines remain as explained earlier


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Dates of service

to

Place of service

Type of service



Diagnosis code


1 3/1/2010 11 66984-54-RT 1 XXX.XX 12 3/1/2010 11 66984-55-RT 1 XXX.XX 1

Diagnosis: 366.16, Nuclear Sclerosis (Surgeon’s Billing)


Dates of service

to

Place of service

Type of service



Diagnosis code


1 3/1/2010 11 V2788 (Presbyopic Cataract Surgery)

1 XXX.XX 1

Diagnosis: 367.4, Presbyopia (O.D.s billing to patient with NEMB)

Billing It Right – Presbyopic IOL Implantation

Example: Billing for 1st EyeDr. Jones performs procedure code 66984 on March 1st and cares for the patient through March 2nd. Dr. Smith assumes responsibility for the patient on March 3rd for the remainder of the global period.


03/01/2010 66984 5403/01/2010 66984 55 assumed 03022010 relinquished 03022010

In addition the surgeon would bill to the patient the additional fee for the non-covered component of implan-tation of the PCIOL with the ICD-9 diagnosis of Presbyopia 367.4.


Dates of service

to

Place of service

Type of service



Diagnosis code



1 XXX.XX 1

Diagnosis: 367.4, Presbyopia (Surgeon’s billing to patient with NEMB)

Dr. Smith’s claim contains the following: 03/01/2010 66984 55 assumed 03032010 relinquished 05302010

In addition to the standard post-operative care the O.D. would also bill their portion of the additional post-operative services provided due to the implantation of a PCIOL with the ICD-9 diagnosis of Presbyopia 367.4.

It is important to note that each physician participating in the care of the patient should independently have the patient sign a Medicare form NEMB (Notice of Exclusion from Medicare Benefits) for their independent services provided.


Dates of service

to

Place of service

Type of service



Diagnosis code


1 3/1/2010 11 66984-55-LT 1 XXX.XX 1

Diagnosis: 366.16, Nuclear Sclerosis (O.D.’s post-operative billing )


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Billing for 2nd EyeDr. Jones performs procedure code 66984 on the 2nd eye on May 1st and cares for the patient through May 2nd. Dr. Smith assumes responsibility for the patient on May 3rd for the remainder of the global period.


05/01/2010 66984 79 5405/01/2010 66984 79 55 assumed 05022010 relinquished 05022010


Dates of service

to

Place of service

Type of service



Diagnosis code


1 5/1/2010 11 66984-79-54-LT 1 XXX.XX 12 5/1/2010 11 66984-79-55-LT 1 XXX.XX 1

Diagnosis: 366.16, Nuclear Sclerosis (Surgeon’s billing - second eye)


Dates of service

to

Place of service

Type of service



Diagnosis code


1 5/1/2010 11 66984-79-55-LT 1 XXX.XX 1

Diagnosis: 366.16, Nuclear Sclerosis (O.D.’s post-operative billing - second eye)

Just as in billing for the first eye, the surgeon would bill to the patient the additional fee for the implantation of the PCIOL with the ICD-9 diagnosis of Presbyopia 367.4.


Dates of service

to

Place of service

Type of service



Diagnosis code



1 XXX.XX 1

Diagnosis: 367.4, Presbyopia (Surgeon’s billing to patient with NEMB - second eye)

Dr. Smith’s claim contains the following:05/01/2010 66984 79 55 assumed 05032010 relinquished 07302010


Dates of service

to

Place of service

Type of service



Diagnosis code



1 XXX.XX 1

Diagnosis: 367.4, Presbyopia (O.D.’s billing to patient with NEMB - second eye)

Similarly, in addition to the standard post-operative care the O.D. would also bill their portion of the addition-al post-operative services provided due to the implantation of a PCIOL with the ICD-9 diagnosis of Presbyopia 367.4.


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As noted in our earlier example of traditional monofocal implantation claims where physicians share post-operative care, the assumed and/or relinquished dates of care must be indicated in Item 19 of the CMS-1500 claim form, or electronic media claim equivalent and the same rules exist where a transfer of post-operative care occurs. Based on the example above, reimbursement for the post-operative care is apportioned as follows (excluding Dr. Jones’s surgi-cal portion corresponding with modifier -54):The maximum percentage for post-operative care for 66984 is 20 percent, and the length of the associated global period is 90 days.

Fee schedule amount for 66984 = $800.00 (For Illustrative Purposes Only)Post-operative days 90Total Post-operative reimbursement if performing 100% of post-operative care (20%) = $160.00

Dr. Jones provided care for the first day. To determine the allowed amount, divide the 1 day by the total number of post-operative days (90). This equals 1.11%. Multiply the 1.11% by the 20% post-operative care amount, thus reim-bursement would equal $1.76.

(1 day divided by 90 days (total post-operative) = 1.11%; 1.11% x $160.00 (20% post-operative) = $1.76)

Dr. Smith provided care for the last 89 days. To determine the allowed amount, divide the 89 days by the total num-ber of post-operative days (90). This equals 98.89%. Mul-tiply the 98.89% by the 20% post-operative care amount, thus reimbursement would equal $158.22

(89 days divided by 90 days (total post-operative) = 98.89%; 98.89% x $160.00 (20% post-operative) = $158.22)

Surgeonbilling

CPT codeused

ICD-9 codeused

Typicalcharges

Coverage

Line 1 66984-54-(RT/LT) 366.16 Nuclear Cataract


Line 2 V2788 Presbyopia Cataract Surgery

367.4 Presbyopia

$1000.00 Non-covered services above traditional cataract - bill to

patientOptometrist

billingCPT code

usedICD-9 code

usedTypicalcharges

Coverage

Line 1 66984-55-(RT/LT) 366.16 Maximum of 20% of surgeon’s fee. Based upon portion of global

post-operative care provided.



367.4 Presbyopia

$500.00 Non-covered services above

Format of typical charges surrounding the patient with cataracts upgrading to a presbyopia-correcting IOL

$1.76 (Dr. Jones)+ $158.22 (Dr. Smith) = $160.00 Total post-operative care

But, recognize in this case that there is also significant, ad-ditional revenue generated by both parties.

ConclusionsThese rulings from CMS certainly sounded a clarion call in policy shift for both patients and physicians. Patients now have the option of having the best technology avail-able to satisfy their visual needs for their lifestyles, and ODs and MDs can provide it without the fear of losing significant revenue. With O.D.’s providing the majority of primary eye care visits in the country, it is vitally important that they are knowledgeable about these technologies and the opportunity that exists by educating their patient base about them. Ophthalmology and optometry can and must work together to bring this exciting new technology to the mainstream. These ruling create a climate for a true win-win-win for the O.D., the M.D., and most importantly for the patient who is able to now have options in their own health care decisions. With the “boomer generation” having less than a year before hitting the Medicare system, we have the tools at our disposal to satisfy their visual de-mands, and preserve their active lifestyles. The government has done its part to create policy that provides us flexibility and options in being able to fulfill our patient demands without financial compromise. Don’t be left out of being a part of these exciting times in eye care – there is no com-pelling reason to remain ignorant – take advantage of the opportunity before you and make the most of it – for your patient, your practice, and yourself.

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Surgeonbilling

CPT codeused

ICD-9 codeused

Typicalcharges

Coverage

Line 1 66984-54-(RT/LT) 366.16 Nuclear Cataract



367.4 Presbyopia

$1000.00 Non-covered services above traditional cataract - bill to

patientOptometrist

billingCPT code

usedICD-9 code

usedTypicalcharges

Coverage

Line 1 66984-55-(RT/LT) 366.16 Maximum of 20% of surgeon’s fee. Based upon portion of global

post-operative care provided.



367.4 Presbyopia

$500.00 Non-covered services above


Dr. Rumpakis is currently President & CEO of Practice Resource Management, Inc., a firm that specializes in providing a full array of consulting, appraisal, and management services for healthcare professionals and industry. He has developed some of the lead-ing web-based software applications for the medical/eye care field such as Reimburse-mentPLUS® (www.ReimbursementPlus.com), the industry leading internet-based CPT Code Information and Reimbursement software program and WhatsMyPracticeWorth.com® (www.WhatsMyPracticeWorth.com), an dynamic online practice appraisal tool. He is also the founder of Opt-ED® Professional Continuing Education which creates and delivers top tier continuing education around the country as well as Opt-IN® which provides optometric marketing and promotional services.

Named the Chief Medical Coding Editor for Review of Optometry, he has been exten-sively published on the topics of third party coding & billing, practice management, team building, maximizing e!ectiveness and profitability, including the textbook “Busi-ness Aspects of Optometry”. Dr. Rumpakis is a popular lecturer both nationally and internationally. In addition to having had a successful solo practice, Dr. Rumpakis devel-oped the practice management curriculum at Pacific University College of Optometry and taught optometric & medical economics there for over a decade.

A 1984 graduate of Pacific University College of Optometry, he currently serves on the AOA’s Congress Committee, was the primary architect of the AOA Advantage program, and has served as chair for the Student Debt Special Project Team, the Gold Disk Proj-ect Team, and the Practice Perpetuation Project Team.

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