Medicare Rules for Computer Assisted Cataract Surgery (ZEISS)
FREQUENTLY ASKED QUESTIONS:
Medicare Rules for Computer Assisted Cataract Surgery
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Q How does ZEISS CALLISTO eye® help the cataract surgeon?
A Computer assisted cataract surgery with ZEISS CALLISTO eye provides tools for the surgeon to precisely and quickly align a toric IOL and make limbal or corneal relaxing incisions. It works with ZEISS OPMI® LUMERA® microscopes to display assistance information in the view of the surgical field and control it with the foot control panel of the surgical microscope.
Q What reimbursement issues affect the use of ZEISS CALLISTO eye?
A The primary reimbursement issue is determining who pays for it. Medicare covers medically necessary cataract surgery but does not cover concurrent refractive surgery such as relaxing incisions to correct astigmatism,1 implantation of a presbyopia-correcting IOL,2 or implantation of an astigmatism-correcting (toric) IOL.3 The charge for refractive surgery, including use of the ZEISS CALLISTO eye, is the patient’s financial responsibility.
Q If the ZEISS CALLISTO eye is used in cataract surgery without refractive surgery, who pays for it?
A All of the equipment used in cataract surgery is covered and reimbursed as part of Medicare’s payment for the facility fee of the ambulatory surgery center (ASC) or hospital outpatient department (HOPD). The type of instruments, techniques or approach used in a procedure is a matter of choice of the surgeon. Like the surgical microscope, computer assistance within the oculars for greater precision during surgery is an incidental part of the procedure and not separately reimbursed for the surgeon or the facility.4 Use of the ZEISS CALLISTO eye during cataract surgery is not the patient’s financial responsibility.
Q If the ZEISS CALLISTO eye is used in corneal transplant surgery without refractive surgery, who pays for it?
A All of the equipment used in medically necessary keratoplasty is covered and reimbursed as part of Medicare’s payment for the facility fee of the ASC or HOPD. Use of the ZEISS CALLISTO eye during keratoplasty is not the patient’s financial responsibility.
Q Are there other noncovered expenses associated with refractive surgery at the time of cataract surgery?
A Yes, many. For the facility, there are additional charges for refractive keratoplasty (LRI, CRI) or a premium IOL (PC-IOL, AC-IOL). For the surgeon, there are additional charges for pre-op testing, intraoperative refractive surgery, and extended postop care after 90 days.
Q What should we tell patients about refractive cataract surgery?
A Patients are given the opportunity to choose between cataract surgery with or without refractive surgery. After the benefits of the surgical correction of presbyopia and/or clinically significant regular astigmatism have been explained, the patient is advised of the extra charge for this service and may be asked to sign a financial waiver form. Payment for non-covered services is the patient’s responsibility.
Q How should we tell Medicare beneficiaries about the noncovered charges associated with refractive cataract surgery?
A Because noncovered items are the financial responsibility of the Medicare beneficiary, it is appropriate to notify the patient prior to surgery about the anticipated out-of-pocket expense and to collect payment in advance. 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; MA Plans may have their own waiver forms.
- For non-Medicare insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
This helps prevent misunderstandings and “buyer’s remorse” afterwards. The facility and surgeon should each execute an ABN.
Q What documentation is required in the patient’s medical record?
A In addition to the financial waiver mentioned above, the surgeon’s operative report should describe the procedures in detail and the reasons for them.
Q How should we track the noncovered services in our billing system?
A Because surgical correction of regular astigmatism is a non-covered service paid by the patient, it is unlikely that a claim will be filed. For bookkeeping purposes and to avoid confusion for the patient, a distinct charge for the relaxing incisions or implantation of a toric IOL should be entered into the patient account. HCPCS code 66999 “unlisted procedure, anterior segment of eye” is useful for this purpose, or you can create an internal code.
If a beneficiary insists that a claim be filed, then report 66999-GY. Modifier GY means an “Item or service statutorily excluded or does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit.” This modifier ensures a denial. Couple this with a diagnosis code to report regular astigmatism (H52.22-).
Q Is it necessary to segregate the ASC charges from the surgeon’s charges?
A Yes. Each entity (i.e., clinic and facility) should separate covered and noncovered charges for the patient and file its own claim, even if owned by the same person(s) or corporation. Medi-care separates the clinic and the ASC by unique identification numbers. Contracts with other payers are discrete. Funds should not be commingled.
1. CMS National Coverage Determination §80.7 Refractive Keratoplasty
2. CMS Ruling 05-01 Presbyopia-correcting intraocular lens, May 2005
3. CMS 1536-R Astigmatism-correcting intraocular lens, January 2007
4. Federal Register Vol 64 No 140 p 39629, Use of operating microscope (CPT code 69990) July 22, 1999
Provided Courtesy of ZEISS (800) 358-8258
Last updated December 1, 2017
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-9 and ICD-10), and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. The reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.
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