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Medicare payment changes never happen as quickly as medical technology advances, but CMS has done a pretty good job keeping up with the advent of and demand for refractive-IOL-implanting procedures. While the payment regulations for these procedures give surgeons and Medicare patients many more options than before, they also create practical payment issues and increase the chances that you may unwittingly violate Medicare payment or fraud and abuse laws. Here are four keys to ensure that your arrangements with surgeons and patients for payment comply with both Medicare billing rules and the federal Anti-kickback Statute.
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How You Get Paid for IOLs |
Here are two coverage rulings you should be aware of when it comes to coding and billing for implanting presbyopia-correcting IOLs in Medicare patients.
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1. Bill for a traditional IOL. Have your billing staff code for the removal of a cataract with insertion of a conventional IOL, regardless of whether a conventional or presbyopia-correcting IOL was inserted. In both cases, payment for the lens itself is packaged into the payment for the surgical cataract extraction and lens replacement procedure. The facility fee is the same for both kinds of IOLs with respect to charges for follow-up visits as well as for the surgery. The only exceptions are lenses classified as "New Technology IOLs" - in that case, you can bill Medicare for an additional $50 per lens (see "How You Get Paid for IOLs" on page 24).
2. Charge a reasonable difference. While CMS has declined to give specific pricing information, its guidelines clearly state that you should charge patients a fair amount for the difference in price between presbyopia-correcting and conventional IOLs. The agency said in Transmittal No. 636 that in determining the beneficiary's liability, you (and the surgeon) should try to account for any additional work and resources required for insertion fitting, vision acuity testing and monitoring of the presbyopia-correcting IOL that exceeds the work and resources attributable to insertion of a conventional IOL. The extra money should also be enough to ensure that you won't appear to be giving patients improper inducement to have their procedures at your facility.
And yet you must be careful to ensure you don't charge what's viewed as an excessive amount, as that could lead to allegations that you've inflated the charges for a non-covered service in order to supplement the Medicare payment for the Medicare-covered services, a violation of the Medicare assignment or limiting-charge rule. As a general rule, you should be safe as long as you charge an amount equal to your additional costs in providing the presbyopia-correcting IOL, plus a reasonable markup.
3. Ensure patients know their payment responsibility. Although a Medicare Advanced Beneficiary Notice isn't technically required because the presbyopia-correcting IOL doesn't fall within a Medicare benefit category, CMS makes clear in Transmittal No. 636 that it's a good idea for you and the surgeon to use this written notice to inform patients that they'll be responsible for an additional fee. At the very least, you should tell patients of their financial responsibility.
4. Take care when procuring the lens. If a surgeon asks whether he can bring the presbyopia-correcting IOLs he purchased direct from the manufacturer, that's fine - there's no rule against it. However, because Medicare's payment to you includes the cost of the IOL, arrange with the surgeon to buy the lens from him for a reasonable price before billing for the procedure - otherwise your bill to Medicare would be a false claim. Be sure to pay the surgeon a reasonable, fair market value price: Pay too much, and you could be subject to the allegation that the excess amount is an inducement to the surgeon for his referrals, a violation of the federal Anti-kickback Statute. If you want to be completely safe, your facility should buy the IOL directly from the manufacturer.
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A Quick Glance at Today's IOLs |
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Alcon
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AMO
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Eyeonics
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Lenstec
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Visiogen
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