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Coding & Reimbursement

Phakic IOLs: How do you get paid?

coding & reimbursement
Phakic IOLs: How Do You Get Paid?

Another opportunity for refractive surgery.

By Suzanne L. Corcoran, COE

Some patients wish to live without eyeglasses or contact lenses and may opt for implantation of a phakic IOL. Currently there are two such lenses: the Verisyse (AMO, Santa Ana, Calif.,) and the Visian (STAAR Surgical, Monrovia, Calif.)

These IOLs are implanted for refractive purposes and are typically not covered by carriers, so this column will explore the payment issues associated with these procedures.

Q. What are the indications for implantation of a phakic IOL? Implantation of a phakic IOL is one option for myopic patients seeking refractive surgery to reduce or eliminate their dependence on eyeglasses or contact lenses.

Q. How are these IOLs implanted? Phakic IOLs are either surgically implanted in the anterior chamber between the cornea and the iris or behind the iris in the ciliary sulcus. Surgery is performed on one eye at a time, with the second eye commonly scheduled within 3 months of the first eye.

This, and other lens implant surgery, is considered permanent. However, should it become necessary to remove the lens, it can be accomplished with a subsequent surgical procedure.

Q. What codes are used to describe this procedure? CPT code 66985, "Insertion of an intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal" describes this procedure. The same code identifies the facility fee for the hospital or ambulatory surgical center (ASC). The facility will also charge for the IOL. One of 3 codes might apply: V2630 - Anterior Chamber IOL; V2631 – Iris supported IOL; or V2632 – Posterior chamber IOL.

Q. Is implantation of a phakic IOL covered by Medicare or other third party payers? No. While Medicare sometimes covers secondary implant procedures, coverage is not extended to procedures performed solely for refractive purposes. For other payers, refractive surgery is rarely a covered benefit.

Generally, if the payer allows coverage for a surgical procedure, coverage is also extended to the required preoperative testing and associated facility fee. However, if the surgical procedure is excluded from coverage, no payment is expected for the associated
services.

Q. How do the surgeon and the facility collect payment from the patient without violating their agreements with payers?

Both Medicare and other third party payers have limitations on coverage. When patients seek services that are not covered under their insurance plans, they must be informed of their financial responsibility. This is accomplished by obtaining the patient's signature on a Notice of Exclusion from Medicare Benefits (NEMB) or Notice of Exclusion from Health Plan Benefits (NEHB).

Q. What if there is a complication later, would the treatment be covered by insurance? Yes, treatment provided to address complications of surgery, such as infection, lens dislocation or ocular hemorrhage, is considered medically necessary care, even if the original procedure is not covered.

While these lens implants are considered elective procedures and are not covered, their popularity continues to grow as patients show a willingness to pay out-of-pocket for refractive surgery.

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565. Sample NEMB and NEHB forms are available on the company's Web site at www.corcoranccg.com.