Surgical Correction of Corneal Astigmatism (Precision Lens)

FREQUENTLY ASKED QUESTIONS:

SURGICAL CORRECTION OF CORNEAL ASTIGMATISM

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Q What options are available for the correction of corneal astigmatism?

A Ophthalmologists have a variety of options available to them for the management of astigmatism. These include spectacles, hard or soft contact lenses, and a variety of surgical procedures. The surgical procedures for correction of corneal astigmatism (SCOCA) include limbal relaxing incisions (LRI), corneal relaxing incisions (CRI), astigmatic keratotomy (AK), photorefractive keratectomy (PRK) and LASIK procedures.

SCOCA may be performed alone or at the same time as other ophthalmic surgery such as cataract surgery.

Q Does Medicare cover surgery to correct corneal astigmatism?

A Rarely. Medicare covers this surgery in the rare instances when it is performed to correct a surgical complication or because of an eye injury or disease. Treatment of regular astigmatism by cosmetic refractive surgery is non-covered.

The mere existence of iatrogenic astigmatism does not automatically make astigmatic correction a covered service. As with all elective surgeries, patient lifestyle complaints, along with trial and failure of prior treatment, need to be well documented in the patient record. Examples of patient complaints include: monocular diplopia interfering with driving and reading, or unable to wear contact lens due to poor comfort. The clinical notes would include discussion regarding trial of spectacles, and possibly contact lenses, without success.

Q Does Medicare specify the amount of surgically induced astigmatism that must be present to be covered?

A Not usually. Only a few Medicare Administrative Contractors (MACs) have ever addressed this in their policies. The Florida MAC previously indicated a 4D change was required and Noridian required a change of 2.5D in astigmatic power. Both of these policies are now retired. Other contractor policies leave it unstated or indicate that medical necessity will be determined on a case-by-case basis.

Q If the payer determines that SCOCA is covered, how should the procedure be coded?

A CPT contains two codes to identify the correction of surgically induced astigmatism. They are defined as:

Do not use these codes to describe refractive surgery to correct pre-existing astigmatism.

Q Why doesn’t Medicare cover procedures to correct astigmatism?

A Procedures performed to reduce or eliminate the patient’s dependence on eyeglasses are not covered. The Medicare National Coverage Determinations Manual (NCD) contains specific instructions about refractive surgery in NCD §80.7 which specifies that “…keratoplasty for the purpose of refractive error compensation is considered a substitute or alternative to eyeglasses or contact lenses, which are specifically excluded… keratoplasty to treat refractive defects are not covered.”

Q Are special tests required prior to SCOCA? Are they covered and paid?

A Prior to SCOCA, there are a number of tests including corneal topography, refraction, wavefront aberrometry, corneal pachymetry, endothelial cell count, and OCT that are useful. When performed in conjunction with a noncovered refractive procedure, the tests are also noncovered and payable by the patient.
In the rare event when SCOCA is required to address significant surgically induced astigmatism, some of these tests may be covered. Within Part B Medicare, refraction is not covered for any reason, but some of the other tests might be.

Q How do we codify refractive surgical procedures for correction of pre-existing regular astigmatism?

A If corneal astigmatism is not due to disease, eye injury, or surgically induced, the correction of astigmatism is considered elective refractive surgery. Use CPT code 66999 (unlisted procedure, anterior segment of the eye) to identify this service. Refractive surgery is not a Medicare benefit.
Some private insurance plans allow coverage. When they do, HCPCS codes S0800 (LASIK), S0810 (PRK), and S9986 (Not medically necessary (patient is aware that service not medically necessary)), are good choices when the payer accepts S-codes. Otherwise, use 66999.

Include modifier GY (Item or service statutorily excluded or is not a contract benefit). We also recommend adding a comment that the claim is being submitted for a denial at the patient’s request, and that the procedure is for “cosmetic refractive surgery”.

Q f coverage of SCOCA is unlikely or uncertain, how should we proceed?

A Explain to the patient that Medicare or other third party payer will likely deny the claim. Ask the patient, in writing, to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.

An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA plans have their own waiver forms or processes and may not use ABN forms.
For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

Q A few insurers cover refractive surgery but pay poorly. How can we get improved payment?

A Not readily. You can try to negotiate a better payment; be sure to do so before you perform the procedure.

In some cases, we find that allied services such as diagnostic tests, anesthesia, facility fees, and postoperative visits are not covered even when the refractive surgery is covered. Itemized billing is helpful in these situations.

Provided Courtesy of Precision Lens (800) 514-1095

Last Updated November 1, 2022

The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, 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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