Noncovered Services with Cataract Surgery (Lenstec)
FREQUENTLY ASKED QUESTIONS:
NONCOVERED SERVICES WITH CATARACT SURGERY
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Q Does Medicare cover all items and services associated with cataract surgery?
A Most items and services associated with routine cataract surgery are covered under Medicare’s national policy (NCD 10.1). There are some things that are not covered and the beneficiary is financially responsible for payment.
Q Why doesn’t Medicare cover everything related to cataract surgery?
A The Medicare law (Social Security Act, Title XVIII) limits health care coverage. Medicare does not pay for everything, even care that beneficiaries or their doctors have good reason to think is necessary. Although Medicare beneficiaries may be disappointed, the fact is that Medicare does not cover routine eye care, specifically refractions, nor does it cover cosmetic surgery including most refractive procedures.1
Q When diagnostic tests are performed during the postoperative period, aren’t they bundled with the surgery?
A Usually not. The Medicare Claims Processing Manual (MCPM), Chapter 12 §40.1B, describes services not included in Medicare’s global surgery package. For example, medically necessary diagnostic tests are outside of the package. So, a final refraction following cataract surgery is not bundled with the global surgery package and not covered by virtue of the Medicare law.
Q But Medicare does cover postcataract eyeglasses. Please explain.
A Under Medicare law (Social Security Act, 1861(s)(8)), beneficiaries are covered for postcataract eyeglasses following cataract surgery with IOL. However, Medicare does not pay for the refraction to prescribe those eyeglasses.2
Q Must a Medicare beneficiary sign an ABN before receiving any non-covered items or services?
A An Advance Beneficiary Notice of Noncoverage (ABN) is only required if something might be covered. However, items and services that are never covered by virtue of exclusions in the Medicare law do not require an ABN. Nevertheless, to avoid “buyer’s remorse”, it’s a good idea to obtain proof that the beneficiary accepts financial responsibility for noncovered items and services. An ABN may be used for this purpose. 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 beneficiaries, a Notice of Exclusion from Healthplan Benefits (NEHB) may be used. Get payment from the patient prior to rendering care.
Q Some ophthalmologists offer pseudophakic monovision to patients. Are there any noncovered charges for it?
A Yes. The patient completes a questionnaire designed to assess the vision requirements in the normal activities of daily living, and the extent of the patient’s desire for spectacle independence. Next, the surgeon performs a battery of preoperative tests to measure ametropias, ocular dominance, stereopsis, and interocular defocus threshold. All of the tests are refractive in nature and the unit of measurement is diopters. Refractions, as well as related refractive tests, are not covered by Medicare.3
Q Are there any noncovered charges for evaluation and treatment of astigmatism at the time of cataract surgery?
A Yes. In addition to refraction, corneal topography is very helpful for assessing corneal astigmatism hinted at by lensometry or detected by keratometry prior to cataract surgery. It is considered a covered test for indications such as post-penetrating keratoplasty, keratoconus, corneal dystrophy or keratopathy, but not for preoperative cataracts. To achieve excellent unaided vision following cataract surgery, astigmatism must be minimized. The surgical correction of pre-existing astigmatism is another noncovered service which should be considered for patients with more than 0.75D of cylinder. Since corneal topography is sometimes covered, an ABN is the appropriate financial notice.
Q What other diagnostic tests might be noncovered?
A Screening for potential disease, such as macular degeneration or epiretinal membrane, using scanning computerized ophthalmic diagnostic imaging of the posterior segment (SCODI-P) is not covered because prophylactic testing is not a Medicare benefit, unless specifically authorized by Congress.
In contrast, testing patients with a history of AMD is a covered service. Likewise, specular microscopy is a covered service under the Medicare national policy where clinically significant corneal pathology is present, as is B-scan for dense cataract.4 Again, use an ABN form in these cases.
Q Are there any noncovered services associated with conventional IOLs within an ambulatory surgery center (ASC)?
A The facility fee associated with performing limbal or corneal relaxing incisions for the surgical correction of corneal astigmatism is noncovered.
Q Some noncovered services are indispensable to the surgeon. Does the patient get to choose whether to have them?
A Yes. Patients need to be fully informed about their care and any financial obligations. It’s the patient’s choice whether to proceed – the patient cannot be forced. If the patient places too many limitations or unreasonable expectations on the surgeon, the ophthalmologist has the option to refuse to provide care.
Q What is the benefit to the patient for noncovered services?
A Cataract surgery has evolved tremendously since the first IOL was implanted in 1949. Modern techniques combine noncovered refractive services with cataract extraction. Surgeons achieve better patient outcomes with less reliance on postcataract eyeglasses due to reduced residual refractive errors.
1 National Coverage Determination for Refractive Keratoplasty §80.7 Link here. Accessed 06/26/16
2 Medicare Benefit Policy Manual Chapter 16 §90. Link here. Accessed 06/26/16
4 National Coverage Determination for Endothelial Cell Photography §80.8 Link here. Accessed 06/26/16
Provided Courtesy of Lenstec, Inc. (866) 536-7832
Last updated July 20, 2016
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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