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Medicare Reimbursement for Treating Astigmatism
For patients with operable cataracts and astigmatism, combining cataract extraction with an IOL implant and the surgical correction of astigmatism can reduce or eliminate their reliance on postoperative corrective lenses. Medicare reimbursement is limited to services deemed medically necessary. It does not pay for cosmetic or refractive surgery except in rare instances when refractive surgery may be covered to correct a surgical complication (Medicare Claims Processing Manual, Chapter 12, §40.1B) or treat the resulting refractive error due to trauma (Transmittal 99). Refractive surgery performed solely to reduce the patient's dependence on eyeglasses or contact lenses would be considered cosmetic under Medicare and therefore excluded from coverage. Furthermore, according to the Medicare National Coverage Determinations Manual NCD §80.7, "keratoplasty for the purpose of refractive error compensation is considered a substitute or alternative to eyeglasses or contact lenses, which are specifically excluded keratoplasty to treat refractive defects are not covered." The surgical correction of astigmatism, by whatever means (eg, limbal or corneal relaxing incisions, astigmatic keratotomy), is a form of keratoplasty and not necessarily a covered service.
The mere existence of iatrogenic astigmatism does not automatically make astigmatic correction a covered service. Before all elective surgeries, the patient's lifestyle-related complaints along with the trial and failure of prior treatment need to be well documented in the patient's record. For example, the complaint might be "monocular diplopia interfering with driving and reading" or "unable to wear contact lens due to poor comfort." The clinical notes would include a discussion regarding a trial of spectacles and contact lenses without success.
The patient represented in Figure 1 experienced a 3.00D increase in astigmatism after cataract surgery. The surgeon should seek reimbursement from Medicare for this procedure. It should be noted that, in rare cases, the increase in astigmatism may be the net change from with-the-rule (+1.50 X 90) to against-the-rule astigmatism (+1.50 X 180) for a total of 3.00D, which may justify surgical correction as a covered service.
Few Medicare carriers have local coverage decisions that specify the amount of surgically induced astigmatism required in order to be eligible for reimbursement. In most states, it is unclear what the criteria are for Medicare-covered astigmatic correction. In cases where coverage is uncertain, an Advanced Beneficiary Notice (ABN) is warranted.
Figure 2 deals with a patient who presents with 2.00D of astigmatism postoperatively that was not surgically induced. In this case, the physician should seek reimbursement from the patient for the surgical astigmatic correction. An ABN is not required, but notifying the patient of required payment is in his and the practice's best interest. Before the operation and during the informed consent, the patent should be asked to sign a Notice of Exclusion From Medicare Benefits.
Figure 3 presents an example of a combined cataract and refractive procedure. Despite the large amount of astigmatism in this case, Medicare would only provide reimbursement for the cataract surgery, and the patient would be responsible for the refractive procedure. Again, a Notice of Exclusion From Medicare Benefits but not an ABN would be appropriate. Filing a claim for an excluded procedure (Figure 4) is useful but not mandatory, because the explanation of benefits sent to the patient would show that the surgical correction of astigmatism was not covered. Some patients have supplemental insurance that might cover the procedure, however.
For surgery performed to correct iatrogenic astigmatism, however, Medicare would reimburse both the HOPD and ASC. When CPT 65772 and CPT 65775 are performed in an HOPD, they fall under Ambulatory Payment Classification (APC) 233. Medicare's national payment rate for APC 233, effective January 1, 2006, is $872.70 (Table 2). When they are combined with other concurrent surgical procedures, the rules for the reimbursement of multiple procedures apply (ie, 50% for the second procedure).
As of July 1, 2003, CPT 65772 and CPT 65775 were included in the list of procedures for which an ASC facility fee is payable under Medicare's regulations. Under current Medicare regulations, CPT 65772 and CPT 65775 are eligible for reimbursement of an ASC facility fee under group 4, with a national reimbursement rate of $630 (effective April 1, 2004) (Table 2).
Kevin J. Corcoran, COE, CPC, FNAO, is President of Corcoran Consulting Group in San Bernardino, California. Mr. Corcoran may be reached at (800) 399-6565; email@example.com. More information on astigmatic correction, including forms mentioned in this article, is available at http://www.corcoranccg.com.