Coding

Laser cataract coding and billing

What you need to know about reimbursements with your femtosecond laser.

By Paul Larson, MBA, MMSc, COMT, COE, CPC, CPMA

It may be hard to believe, but this year marks the fifth anniversary of the use of the femtosecond laser in cataract surgery in the United States. To many, the technology still seems so new. The process of coding and obtaining proper reimbursement for laser cataract surgery is complex enough to warrant a two-part article. In this first part, we focus on a simple question with a complex answer. The question: Who pays for the surgery and associated testing if we use the femtosecond laser in cataract surgery?

What will insurance cover

Insurance companies pay a fixed, negotiated rate for a “package of services” that includes:

■ Some preoperative work.

■ The actual surgery to remove the lens and replace it with an IOL.

■ Basic postoperative care.

The monofocal IOL and the viscoelastics are part of this package. Injections, drops, and supplies, such as the infusion solution and tubing, are also part of this payer package. Payers refer to this as the “global surgery package.”

Golden scalpel

When an insurance payer is involved, the payment remains the same whether a surgeon uses instruments of stainless steel, diamond, lasers, or even a scalpel made of 24-carat gold. Even the “golden scalpel” would not make the procedure worth more to the payer. The same principle applies when a practice has two phacoemulsification machines. The payment from the insurance company is the same regardless of the machine used. Payers don’t care how surgeons perform the surgical steps, the net payment and coverage is the same regardless. Using the laser to perform these steps does not provide a reason to bill the patient unless there is no insurance involved, such as the case with clear lens exchange for refractive reasons where no cataract is implicated.

For covered cataract surgery, the situation is complex when the laser is involved. To clarify, CMS released a document in 2012 that specifically mentions the femtosecond laser. In the document, CMS states: Services that are part of cataract surgery with a conventional lens, including, but not necessarily limited to the incision by whatever method, capsulotomy by whatever method, and lens fragmentation by whatever method, may not be charged to the patient.

Medicare coverage and payment for cataract surgery is the same irrespective of whether the surgery is performed using conventional surgical techniques or a bladeless, computer controlled laser.

Upgrades

However, Medicare does recognize that a single procedure and a single device can have both a covered and noncovered service. Providers and facilities can charge patients under certain circumstances when they are not covered, for example, in the case of astigmatism and presbyopia-correcting IOLs. When these IOLs are used, the patient is allowed to choose to upgrade and pay for the difference. As CMS puts it:

If the bladeless, computer controlled laser cataract surgery includes implantation of a PC-IOL or AC-IOL, only charges for those non-covered services specified above may be charged to the beneficiary. These charges could possibly include charges for additional services…”

The document includes references to the slightly longer CMS rulings on these types of “upgraded” IOLs.

Non-covered services

That leaves what isn’t part of the “payer package”—things that are not integral or a direct part of cataract surgery. Many of these services may be billed to the patient by the respective billing facility or surgeon. Figure 1 provides a convenient way to decide whether something is covered (thereby in the “global surgery” payer package—and not billable to patient) or possibly noncovered (patient-pay). While the table uses Medicare guidance, other payers generally agree. OP

References:

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.