Medicare Reimbursement for IOLs used in Cataract Surgery

Medicare and other third party payers reimburse the facility where surgery is performed: either the ambulatory surgery center (ASC) or hospital outpatient department (HOPD).  Medicare reimbursement for the IOL is part of APC-246.  While most third party payers follow Medicare’s approach, some payers make separate reimbursement for IOLs.  When listed separately, HCPCS codes V2630, V2631 and V2632 are used to identify an IOL.

This FAQ addressed the following:

  1. Who is reimbursed for intraocular lenses (IOLs) used in cataract surgery?
  2. Is payment ever made to the surgeon for the cost of the IOL?
  3. May the surgeon purchase an IOL directly from a manufacturer?
  4. May the surgeon purchase an IOL from the manufacturer and bill it directly to the patient?
  5. May the surgeon purchase an IOL from the manufacturer and resell it to the facility?
  6. When the IOL is reimbursed separately, may the HOPD or ASC mark up the price of the IOL?
  7. What is the beneficiary’s financial liability for the IOL?
  8. Is there a limit to the charge for the upgrade for a P-C IOL or toric IOL?
  9. May the surgeon collect payments for all of the non-covered items and services?

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