Just when coders were beginning to believe that they'd mastered the ins and outs of ophthalmology coding, along come presbyopia-correcting IOLs to create a new set of billing challenges.

Whether you're an administrator, a coder, a nurse or a surgeon, you've no doubt heard the buzz about Crystalens by Eyeonics, AcrySof ReStor by Alcon and AMO's ReZoom, the new IOLs that combine the effects of refractive and cataract surgery, reducing the dependency on eyeglasses for many. Chances are you'll soon be implanting these lenses, each of which has the same steep list price: $895, only $150 of which Medicare will cover.

"Great, now I have to code for a lens"
You might be wondering how you can get reimbursement for this lens if the patient has Medicare. Wouldn't that be balance billing? The answer, perhaps surprising, is no.

According to Medicare, this is a non-covered service for which you can bill the patient. CMS published a ruling on May 3 stating that Medicare will pay for the standard cataract surgery facility fee ($980) and the standard new-technology IOL ($150). The patient is responsible for the difference in price between the new lens and the standard IOL. Notably, the CMS ruling doesn't tell you how much to charge the patient, only that the patient is "responsible for payment of that portion of the charge for the presbyopia-correcting IOL and associated charges that exceed the charge for insertion of a conventional IOL."

As always, though, not all insurance companies are following the guidelines set forth by Medicare. It's imperative to verify coverage before the procedure. In any case, make sure your patient is fully aware of his out-of-pocket costs.

What to do before surgery
Patient out-of-pocket costs will vary according to each patient's insurance plan and your charge for the lens. Before surgery, make patients aware of the potential maximum out-of-pocket costs. You might want to provide the patient with a detailed explanation of how you'll determine his costs. Although you'll probably not be able to give the patient a set fee on the day of surgery, you'll be able to provide him with a breakdown of costs.

At the same time, have the patient sign a notification of exclusion stating that he's aware of the additional costs he's incurring and he agrees to be responsible for any and all amounts remaining after his insurance reimbursement. I also recommend collecting partial payment for the surgery beforehand; at the very least, you should collect the co-insurance for the cataract surgery - usually between $180 and $200.

No new cataract codes
CMS Transmittal 636 announced on Aug. 5 that "no new codes are being established at this time to identify a presbyopia-correcting IOL or procedures and services related to a presbyopia-correction IOL." So you have two choices for billing cataracts, 66984 and 66982.

• 66984. Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (irrigation and aspiration or phacoemulsification, for example).
• 66982. Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (irrigation and aspiration or phacoemulsification, for example), complex, requiring devices or techniques not generally used in routine cataract surgery (iris expansion device, suture support for intraocular lens or primary posterior capsulorrhexis, for example, or performed on patients in the amblyogenic development stage).

For tracking purposes and secondary claim reimbursement, it'll be useful to assign codes to the non-covered lenses. Additionally, commercial payers may require a HCPCS code before they'll reimburse the lens. See "HCPCS Codes for Non-covered Lenses" for a list of applicable codes and when you should use them.

Contingent upon the post-operative diagnosis, you'll use the standard 366.xx cataract diagnosis codes. Additionally, these modifiers can also apply:

Are you prepared?
Surgeons need to be rather selective in determining which patients are candidates for the new lenses, as not every patient with a cataract is eligible for the new IOL. In addition to objective evidence of a cataract, a patient must desire to be free of reading glasses and be willing to pay more for a procedure and lens to be considered a candidate for the new lenses. You shouldn't consider for this type of lens patients at a higher risk for certain complications, including pupils that don't dilate.

Finally, stay in touch with your vendors, many of whom have additional information on the lenses to ensure that your facility is fully knowledgeable about the new lenses and reimbursement issues that may arise. Until next time, happy coding.