Laser technology has advanced the field of ophthalmology tremendously during the past 4 decades, and the majority of our subspecialties employ laser technology almost on a daily basis. Most recently, femtosecond laser cataract extraction has become commonplace in many regions of this country. With the advent of new techniques and procedures comes inevitable discussion of how to use them to maximally benefit patients and, furthermore, how to have the patient share in the expense of the laser as well as the ophthalmologist’s extra testing and time spent on the case.
There has been a nationwide debate as to whether or not it is appropriate to charge a patient for services that are already covered for a routine cataract surgery. The information herein is in accordance with the American Academy of Ophthalmology (AAO) as per its website, aao.org, as of July.
MEDICALLY NECESSARY CATARACT EXTRACTION WITH A PREMIUM REFRACTIVE IOL (NO ASTIGMATIC KERATOTOMY)
The AAO states, “Neither the surgeon nor the facility should use the differential charge allowed for implantation of a premium refractive IOL to recover all or a portion of the costs of using the femtosecond laser for cataract surgical steps. As set forth above, Medicare Part B covers the cataract surgery and the implantation of a conventional lens without regard to the technology used.
“Imaging performed as part of the femtosecond laser surgery, which is necessary to implant premium refractive IOLs, is considered a noncovered service, as long as these services are not used routinely when implanting conventional IOLs. A separate charge for the imaging is allowed with that consideration. However, as set forth above, Medicare Part B covers the cataract surgery without regard to the technology used. The Medicare beneficiary receiving a premium refractive IOL may be charged for noncovered services (such as imaging), but not for using the femtosecond laser to perform covered steps of cataract surgery, such as the phaco incision, capsulotomy, and lens fragmentation.”
MEDICALLY NECESSARY CATARACT SURGERY PLUS ASTIGMATIC KERATOTOMY PERFORMED FOR REFRACTIVE INDICATIONS
The AAO's website continues, “Medicare will cover medically necessary cataract surgery, but not concurrent correction of astigmatism performed for refractive indications. Medicare patients may be charged a fee for performing astigmatic keratotomy, assuming that they were informed about, and consented to, the noncovered charges in advance. Because astigmatic keratotomy for refractive indications is a noncovered service, a higher fee can be charged for performing it using the femtosecond laser, instead of with a metal or diamond blade. As with premium IOLs, however, the patient should not be charged an additional amount to concurrently perform the cataract surgical steps with the femtosecond laser.”
Therefore, it can be deduced that the safe harbor for patient-shared billing associated with the use of a femtosecond laser for cataract extraction is in conjunction with premium IOL implantation for the imaging associated with the capsulotomy placement and for an astigmatic keratotomy to improve refractive outcomes for patients receiving monofocal and premium IOLs.
COST OF THE LASER AND VARIABLES
The decision for a surgery center to purchase a femtosecond laser for its surgeons carries significant costs. The units themselves cost approximately $400,000 to $500,000. Furthermore, each laser has an associated usage or “click” fee for the disposable components associated with each case of $300 to $400 per case and requires maintenance and additional personnel. Most ophthalmic ambulatory surgery centers have a facility fee that must be implemented for these cases to help defer the additional cost. Facility fees likely range from center to center within different regions of the country.
Surgeons must also factor in the potential extra costs that may be incurred with the utilization of a femtosecond laser. These costs include additional chair time as well as topographic and retinal evaluation with optical coherence tomography. Many surgeons also include excimer laser enhancements at no charge as part of a premium package. When using the femtosecond laser to perform cataract surgery in one of the previously described scenarios, the patient may be charged an extra fee for these noncovered services.
Pricing for an amplified procedure is based on different contributing factors. Many variables such as the facility fee, premium IOLs, or simple astigmatic reduction will contribute to the appropriate fee schedule for each individual practitioner. The most important issue is for a practice to attempt to keep the fees constant for the services that are provided. This makes for an easier interaction between the patient, physician, and staff, and it creates a better overall experience for everyone involved.
When new technology is launched into the active workplace, questions will arise as to who will be candidates for the procedures and who should help fund them. The Centers for Medicare & Medicaid Services has issued rulings with regard to femtosecond laser cataract extraction. It is legitimate to balance bill for premium IOLs utilizing the imaging technology to improve the centration of the capsulotomy and, presumably, the refractive outcome. Furthermore, it is legitimate to balance bill for an arcuate incision to reduce astigmatism even with a standard monofocal implant. The pricing for such technologies is multifactorial and will vary from region to region.
Robert J. Noecker, MD, MBA, practices at Ophthalmic Consultants of Connecticut in Fairfield. Dr. Noecker may be reached at (203) 366-8000; firstname.lastname@example.org.
Jonathan Stein, MD, is in practice at Ophthalmic Consultants of Connecticut in Fairfield and is a clinical assistant professor at the NYU School of Medicine in New York City. Dr. Stein may be reached at email@example.com.