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:

1. What documentation does Medicare require when the patient elects implantation of a premium IOL?
2. What documents do non-Medicare payers require?
3. What should we tell patients about the out-of-pocket expense for the non-covered items and services?
4. What is the charge for the premium IOL?
5. If the surgeon owns the ASC, is it still necessary to segregate the ASC charges from the professional fees?
6. How does the facility represent the lens charge on a claim form?
7. Are specific codes assigned and reported to Medicare or other payers to describe the non-covered items or services?

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