Article

Coding & Reimbursement

Cataract surgery, CMS and what falls under “noncovered”

Medicare covers most items and services associated with regular cataract surgery. Under the national policy, this includes a comprehensive eye exam, biometry with IOL calculation and, when necessary, a B-scan for dense cataract.1 But some things are not covered, and the beneficiary is financially responsible for payment.

Q. Why doesn’t Medicare cover everything related to cataract surgery?

A. Medicare does not pay for everything, even care that beneficiaries or their doctors have good reason to think is necessary. The Medicare law (Social Security Act, Title XVIII) limits health-care coverage. Although Medicare beneficiaries may be disappointed, the fact is that Medicare does not cover routine eye care, specifically refractions, nor does it cover cosmetic surgery, including most refractive procedures.2 Services associated with presbyopia- or astigmatism-correcting IOLs are also noncovered for the same reason.

Q. But Medicare covers postcataract eyeglasses. Please explain.

A. Under Medicare law (Social Security Act, 1861(s)(8)), beneficiaries are covered for postcataract eyeglasses following cataract surgery with IOL. However, Medicare does not pay for the refraction to prescribe those eyeglasses.3

Q. What about diagnostic tests? Are they bundled with the surgery?

A. Usually not. The Medicare Claims Processing Manual describes services not included in Medicare’s global surgery package.4 For example, medically necessary diagnostic tests are outside of the package. A final refraction following cataract surgery is not bundled in the global surgery package but not covered by virtue of the Medicare law.

In addition, screening for potential disease, such as AMD or epiretinal membrane, using OCT (92134) is not covered because prophylactic testing is not a benefit, unless specifically authorized by Congress. In contrast, testing patients with a history of AMD is a covered service.

Likewise, specular microscopy where clinically significant corneal pathology is present is a covered service under the Medicare national policy.5 Neither is covered for a diagnosis of cataract.

Q. Some ophthalmologists offer pseudophakic monovision to patients. Are any noncovered charges related to it?

A. Yes; usually the patient completes a questionnaire assess vision requirements in the normal activities of daily living and the extent of the patient’s desire for spectacle independence. Then, the surgeon performs preoperative tests to measure ametropias, ocular dominance, stereopsis and interocular defocus threshold. All tests are refractive in nature and the unit of measurement is diopters. Medicare does not cover refractions and related refractive tests.

Q. What about evaluation and treatment of astigmatism at the time of cataract surgery?

A. In addition to refraction, corneal topography is very helpful for assessing corneal astigmatism hinted at by lensometry or detected by keratometry prior to cataract surgery. It is considered a covered test for indications such as post-penetrating keratoplasty, keratoconus, corneal dystrophy or keratopathy — but not for preoperative cataracts.

To achieve excellent unaided vision following cataract surgery, astigmatism must be minimized. The surgical correction of pre-existing astigmatism is another noncovered service that should be considered for patients with more than 0.75 D of cylinder. Because corneal topography is sometimes covered, an Advance Beneficiary Notice of Noncoverage (ABN) is the appropriate financial notice.

The facility fee associated with performing limbal or corneal relaxing incisions for the surgical correction of corneal astigmatism is also noncovered. As such, the ASC can — and should — collect from patients for these services. Of course, an appropriate financial waiver is required.

Q. Must a Medicare beneficiary sign an ABN before receiving any noncovered items or services?

A. An ABN is required only if something might be covered.6 However, items and services that are never covered by virtue of exclusions in the Medicare law do not require an ABN. Nevertheless, to avoid “buyer’s remorse,” it’s a good idea to obtain proof that the beneficiary accepts financial responsibility for noncovered items and services. An ABN may be used for this purpose.

For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services. MA Plans have their own waiver processes and are not permitted to use the ABN form. Check with the plans. For non-Medicare beneficiaries, a Notice of Exclusion from Health Plan Benefits may be used.7 In all cases, we recommend that you get payment from the patient before rendering care.

Q. Some noncovered services are indispensable to the surgeon. Does the patient get to choose whether to have them?

A. Yes. Patients must be fully informed about their care and any financial obligations. It’s the patient’s choice whether to proceed — the patient cannot be forced. If the patient places too many limitations or unreasonable expectations on the surgeon, the ophthalmologist has the option to refuse to provide care. OM

REFERENCES

  1. CMS. Medicare national coverage determination for use of visual tests prior to and general anesthesia during cataract surgery. NCD 10.1. https://tinyurl.com/yao78e48 . Accessed Sept. 5, 2018.
  2. CMS. Medicare national coverage determination for refractive keratoplasty. NCD 80.7. https://tinyurl.com/yc7fcuxv . Accessed Sept. 5, 2018.
  3. CMS. Medicare Benefit Policy Manual, Chapter 16. §90. https://tinyurl.com/yaq4y2jd . Accessed Sept. 5, 2018.
  4. CMS. Medicare Claims Processing Manual, Chapter 12. §40.1B. https://tinyurl.com/y9pfyn7r . Accessed Sept. 5, 2018.
  5. CMS. National coverage determination for endothelial cell photography. NCD 80.8. https://tinyurl.com/ya7jkc8v . Accessed Sept. 5, 2018.
  6. Corcoran Consulting Group. ABN form. https://www.corcoranccg.com/products/forms/abn-advance-beneficiary-notice/ . Accessed Sept. 5, 2018.
  7. Corcoran Consulting Group. NEHB form. https://www.corcoranccg.com/products/forms/nehb-notice-of-exclusion-from-healthplan-benefits . Accessed Sept. 5, 2018.