Reimbursement for Premium IOLs
“Premium” IOLs include presbyopia- correcting IOLs (P-C IOLs) and astigmatism-correcting IOLs (toric IOLs). Other than the usual medical records, patients must be notified, in advance, of financial responsibility, and agree to pay for the non-covered items and services associated with a premium IOL.
For Medicare beneficiaries with visually significant cataract, the August 5, 2005 CMS Transmittal 636 concerning P-C IOLs, and Transmittal 1536-R concerning toric IOLs, advocate the use of waiver1 to clearly identify the non-covered items and services and the associated fees. The facility and surgeon should each execute a waiver. The revised Advance Beneficiary Notice of Noncoverage (ABN) may also be utilized. Do not include these forms with the claim for reimbursement.
This FAQ addresses the following:
- What documentation does Medicare require when the patient elects implantation of a premium IOL?
- What documents do non-Medicare payers require?
- What should we tell patients about the out-of-pocket expense for the non-covered items and services?
- What is the charge for the premium IOL?
- If the surgeon owns the ASC, is it still necessary to segregate the ASC charges from the professional fees?
- How does the facility represent the lens charge on a claim form?
- Are specific codes assigned and reported to Medicare or other payers to describe the non-covered items or services?
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