New codes are always of interest, but they also present challenges. The new Category III CPT code for intraoperatively aligning the visual axis is no exception.
Q. What is intraoperative visual axis identification using patient fixation?
A. During cataract surgery, the surgeon relies on anatomical markers for orientation, chiefly the pupil. In a normal eye, with monocular fixation under the operating microscope, the corneal light reflex that corresponds with the visual axis is displaced nasally about 0.5 mm from the center of the pupil; this is known as positive angle kappa.
Patients vary and so does the degree and direction of the displacement. Intraoperative visual axis identification uses light reflected from the operating microscope to guide placement of the capsulorhexis and to center the IOL independent of the location of the dilated pupil.
This is important because, for an optimal outcome, the center of the IOL should align with the visual axis. Small amounts of decentration (<0.4 mm) are usually tolerated, but large amounts of decentration may cause unwanted visual symptoms of glare and decreased contrast sensitivity, particularly for aspheric and multifocal IOLs. Decentration of the IOL is more likely when the capsulorhexis is irregular or not centered on the visual axis.
Q. How is it performed?
A. In the operating room, the center of a dilated pupil is generally not in the same location as in an undilated pupil; however, the corneal reflex is not affected by mydriasis. Before proceeding with the capsulorhexis or aligning the IOL, the patient is instructed to fixate on a coaxial light so the surgeon can locate Purkinje image 1 — the brightest corneal reflex. Comparing the preop and intraop pupil position relative to the corneal reflex helps guide the surgeon to center the capsulorhexis and IOL on the visual axis.
In the December 2018, issue of CPT Assistant, it states, “the surgeon and the patient review how to perform fixation on the surgeon’s command and the need to keep the patient more awake at the beginning of surgery to allow the patient to better fixate during the procedure.”
Q. How is this coded?
A. Use add-on code +0514T (intra-operative visual axis identification using patient fixation) together with 66984 or 66982 on claims for dates of service Jan. 1, 2019 or later. Note that +0514T cannot stand alone on a claim.
Q. Does Medicare cover this?
A. For the facility where surgery is performed, it is covered. For HOPDs, CMS assigned an N status indicator to +0514T, which means, “Items and services packaged into APC rates; paid under Outpatient Prospective Payment System (OPPS); payment is packaged into payment for other services. Therefore, there is no separate APC payment.” For ASCs, CMS assigned an N1 status indicator to this code, which means the same thing. As an incidental (bundled) covered service, the patient may not be charged other than the applicable deductible and co-payment.
For the surgeon, the answer is unknown. In the 2019 Medicare Physician Fee Schedule, CMS did not assign a payment rate; all Category III codes are assigned C status, which means the service is carrier-priced. A representative policy is contained in the Noridian article, A55607, on coverage and pricing for Category III CPT codes. It states, “Noridian has not received sufficient information to make coverage and pricing determinations.” They further instruct, “Noridian will send an Additional Documentation Request (ADR) letter requesting specific documentation along with the full text copies of the peer-reviewed medical literature, supporting the safety and effectiveness of the service for Medical Director review.”
Q. Is the patient financially responsible for any part of this service?
A. Maybe. Medicare and other third-party payers make individual coverage and payment determinations. As a rule, patients are only financially responsible for noncovered services, and then only if given proper notice in advance of the procedure that it is probably not covered.
Q. If coverage is uncertain or doubtful, how should the surgeon proceed?
A. Explain to the patient why the procedure is necessary and that Medicare or other third-party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.
An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; Medicare Advantage plans may have their own waiver forms or processes and are not permitted to use Medicare ABN forms. For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN. OM