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

FREQUENTLY ASKED QUESTIONS: 

SURGEON’S MEDICARE REIMBURSEMENT RELATED TO AN INTRAOCULAR TELESCOPE

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Q  What are some of the considerations of the cornea specialist prior to implantation of the intraocular telescope?

A  Following the recommendation of the retinologist and the low vision specialist(s), the surgeon’s evaluation of the anterior segment considers a number of variables, including but not limited to: presence of cataract, prior intraocular surgery, and the overall health of the cornea.

 

Q  How does the surgeon report the initial evaluation?

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

Additional reimbursement is made for medically necessary diagnostic testing such as biometry (76519 or 92136).  Specular microscopy (92286) is reimbursed when corneal disease is identified, but otherwise treated as an incidental part of the eye exam where corneal disease is absent (NCD 80.8).1.

 

Q  What is the surgeon’s reimbursement for the procedure?

A  As of July 1, 2012, a new CPT Category III code 0308T was established.2.,3.  It describes “Insertion of ocular telescope prosthesis including removal of crystalline lens”.  The words “or intraocular lens prosthesis” were added to the end and became effective on January 1, 2016.  Parenthetical notes state: “Do not report 0308T in conjunction with 65800-65815, 66020, 66030, 66600-66635, 66761, 66825, 66982-66986, 69990.

Medicare does not assign Relative Value Units or a payment rate to Category III CPT codes.  Reimbursement is determined on a case-by-case basis at the discretion of the MAC; a copy of the operative report is usually required.

 

Q  Does subsequent care by the low vision specialist(s) qualify as co-management of postoperative care?

A  No.  First, it is very unlikely that the surgeon would delegate postoperative care in these challenging cases, and co-management does not apply without that delegation.4.  Second, a low vision specialist focuses attention on “…rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills”.5.

 

Q  Does subsequent care by the low vision specialist(s) qualify as co-management of postoperative care?

A  No.  First, it is very unlikely that the surgeon would delegate postoperative care in these challenging cases, and co-management does not apply without that delegation.4.  Second, a low vision specialist focuses attention on “…rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills”.5.

 

Q  If a patient experiences difficulty 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.6.

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).7.

 

Q  What is the effect on reimbursement when the cornea and the retina doctors see the patient on the same day?

A  When two ophthalmologists are part of a group practice and both see the patient on the same day with encounters for the same reason, Medicare expects to receive a claim for only one exam from the group.8.  In this case, combine all of the elements of both exams to arrive at a single code for the combination.  Providers who are not part of the same group practice are not affected; each provider bills as usual.

 

Q  If the exams for the surgeon and retinal specialist in the same group occur on different days, does that matter?

A  Yes.  When the exams are on separate days, each may be billable, although the first exam is generally greater than the second.  Be sure to bill only for those elements of the history and exam that are necessary to repeat at the second exam, since doctors in a group practice share the patient’s medical record.

 

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 one for the purposes of postoperative care when the operated eye is being re-evaluated.  Where the ophthalmologists are in separate practices, the services of the retinologist are distinct and not part of the surgeon’s postoperative care.

 

1.  CMS.  National Coverage Determination §80.8.  Endothelial Cell Photography.  Rev. eff. 08/31/1992. 

2.  CMS.  Transmittal 2468.  July 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 13.2.  May 11, 2012. 

3.  CMS.  Transmittal 2483.  July 2012 Update of the Hospital Outpatient Prospective Payment System (OPPS).  June 8, 2012.

4.  Medicare Claims Processing Manual Chapter 12, §40.2. 

5.  CMS.  PM Transmittal AB-02-078.  Provider Education Article:  Medicare Coverage of Rehabilitation Services for Beneficiaries With Vision Impairment.  May 29, 2002. 

6.  Ibid.

7.  Medicare Claims Processing Manual Chapter 12, §40.1.B. 

8.  Medicare Claims Processing Manual Chapter 12, §30.6.5. 

 All links 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.

 

© 2016 Corcoran Consulting Group.   All rights reserved.  No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher.

 

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