Retinologist’s Medicare Reimbursement Related to an Intraocular Telescope (VisionCare Ophthalmic Technologies)

FREQUENTLY ASKED QUESTIONS: 

RETINOLOGIST’S MEDICARE REIMBURSEMENT RELATED TO AN INTRAOCULAR TELESCOPE

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Q  What are the considerations of the retinologist prior to recommending implantation of the intraocular telescope?

A  Before considering implantation of the intraocular telescope, the retinologist will assess candidacy based on a number of factors.  First and foremost, the eligible candidate is someone with stable, end-stage, age-related macular degeneration (AMD) with bilateral loss of central vision and visually significant cataract.  Exclusion criteria include:  age (<65 y/o), pseudophakia, prior intraocular surgery, corneal disease, unstable retinal disease, and inadequate peripheral vision in the fellow eye.  Significantly, the patient must be willing to work closely with a low vision specialist(s) before and after surgery to achieve rehabilitation.

 

Q  How does the retinologist report their evaluation?

A  Use E/M (992xx) or eye exam (920xx) codes for the initial evaluation.  Within the Medicare system, outpatient consultation codes (9924x) are no longer accepted.

Additional reimbursement is made for medically necessary diagnostic testing such as fluorescein angiography (92235) and SCODI-retina (92134).

 

Q  Does the retinologist make the decision for surgery?

A  No, the retinologist recommends the patient for consideration of implantation of the intraocular telescope.  The decision for surgery rests with the cornea specialist who will remove the crystalline lens and implant the prosthetic device.

 

Q  What is the retinologist’s role during the postoperative period?

A  The retinologist provides continuing care for any retinal disease in the unoperated eye.  Those services are not part of postoperative care.  In the event that there is a surgical complication following implantation of the intraocular telescope, the retinologist might be asked to provide assistance.  Otherwise, the cornea specialist will handle all of the postoperative care.

 

Q  If there is a problem during the postoperative period, is additional reimbursement available?

A  Sometimes.  When a complication requires a return to the operating room for further surgery, then Medicare has a provision for additional reimbursement.1.

For complications that are managed in-office, the payment of the global surgery fee includes those services, with the notable exception of diagnostic testing to assess the complication(s).2.

 

Q  If the patient returns to the retinologist during the postoperative period, how does Medicare handle those claims?

A  Where the retinologist and the surgeon are in the same group practice, the Medicare program will treat both ophthalmologists as if they are the same person for the purposes of post-operative care.  Where they are in separate practices, the services of the retinologist are distinct and not part of the surgeon’s postoperative care and may be billable.

 

1.  Medicare Claims Processing Manual Chapter 12, §40.2.A.5.  Accessed 03/17/16.

2.  Medicare Claims Processing Manual Chapter 12, §40.1.B.  Accessed 03/17/16.

 

Provided Courtesy of VisionCare Ophthalmic Technologies, Inc. (888) 999-4134

 

Last updated March 29, 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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