Coding
Femtosecond laser coding
Part two of our dissection of billing and coding for laser cataract surgery
BY PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA
In part two of our look into billing and coding for femtosecond laser cataract surgery, we’ll review notifications to patients, the forms that might be needed and what codes might apply to the packages and surgeries when a femtosecond laser is involved.
Patients often believe their insurance covers everything. Of course, we know this isn’t the case. It’s our duty to explain to patients the difference between covered and non-covered items and procedures. When an item is not covered, it is generally the patient’s choice to either pay for it or not receive the service. Any misinformation you provide could damage the patient’s relationship with the doctor and the facility. Patients might seek care elsewhere. In today’s social-media atmosphere, where patients share with the world their negative experiences, it could cost you and your practice. Additionally, if payers discover that you are passing out incorrect information, they could consider your office in contractual violation and require you to refund monies collected. If the problem is pervasive, your office could be expelled from insurance networks and possibly lose access to their beneficiaries.
Forms
When an item is clearly noncovered and patient-pay, the Advance Beneficiary Notice (ABN) is not required, but CMS notes that you can voluntarily issue one “to forewarn beneficiaries of their financial liability prior to providing care that Medicare never covers.” Other insurers generally have some form that serves a similar purpose; they may even require you to issue it (in their view, it’s not voluntary). Since questions might arise later, the form is evidence of the discussion and agreement by the patient of his or her responsibility for payment of the deluxe, noncovered services.
Listing individual “line items” for every service is unnecessary — you could list the various services to be provided and categorize them by the reason for noncoverage on the form (typically, the deluxe services in femtosecond laser cataract surgery are for “screening,” “refractive/cosmetic” or “noncovered diagnoses” reasons).
Medicare coding for noncovered services
For Medicare claims for the noncovered services, there is no perfect code, but there are several options; all depend on which code(s) the carrier will accept. The best options are:
• HCPCS S9986 (Not medically necessary service, patient is aware that service is not medically necessary)
• HCPCS A9270 (Non-covered item or service)
• CPT 92499 (unlisted ophthalmological service or procedure)
• CPT 66999 (unlisted procedure, anterior segment of the eye)
Aside from the administrative burden, a potential problem with using the last two (unlisted CPT codes) is that these claims may be paid in error. The patient will then receive a notice of coverage, which is exactly what you don’t want and already know to be wrong. S9986 is the most accurate descriptor for the package of services, although Medicare does not accept S-codes; A9270 may be a suitable fallback for Medicare if your MAC will accept it. Include the fee for the service previously explained to the patient on the claim as well.
If femtosecond limbal relaxing incisions (a noncovered item if done for regular astigmatism not caused by prior surgery) appear on the claim, the most appropriate procedure code to use is 66999; the corresponding diagnosis code is 367.21. Other payers may specify other codes.
It’s also important with noncovered items on claims to denote that a denial is expected by using modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit).
Claims
Next, decide whether to file claims for services that have no coverage. That conclusion will depend on the payer. In some situations, it may be necessary to include these items or services on the claim. For example, a commercial payer may require it, or the patient may desire a denial from Medicare or another payer for submission to a secondary payer, a flexible spending fund, or a health savings account (HSA). Some patients just want something official to corroborate what they have been told.
Deluxe coverage
So what does “deluxe” mean when surgery is involved? In this context, it involves the patient election for more than a basic covered benefit. In eye surgery, the classic example is deluxe or premium IOL options such as those of the toric- and presbyopia-correcting variety. The payer has established a preset covered amount for the basic IOL within covered cataract surgery and permits you to collect from the beneficiary for any additional amount more than the covered item, when the add-on is elective and has no coverage. It is important to note that this isn’t “balance billing,” which is a serious contractual violation. Claim submission would include two or more distinct line items on the claim form to distinguish between the covered and non-covered services.
Filing noncovered items
If claims are filed for noncovered items or services, both a procedure code and a diagnosis code are necessary. For femtosecond laser cataract surgery, this service is generally found within a package of physician services that constitute “deluxe” care (generally for presbyopia and regular astigmatism). Diagnosis coding is straightforward; for femtosecond laser cataract surgery as part of a package, this is generally regular astigmatism (367.21) and/or presbyopia (367.4) if an LRI is performed via a femtosecond laser.
These tips should be seen as a quick guide to understanding this complex subject and help dispel some of the misinformation out there. As always, “good coding” to you! OP
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Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta. |
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