Reimbursement for Implantation of Verisyse™ Phakic IOL (Abbott Medical Optics)

FREQUENTLY ASKED QUESTIONS: 

REIMBURSEMENT FOR IMPLANTATION OF VERISYSE PHAKIC IOL

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Q  What is the Verisyse Phakic Intraocular Lens?

A  The Verisyse Phakic IOL is an anterior chamber, iris-fixated phakic IOL used in the treatment of moderate to high myopia.  The lens is available in 5mm (-5 D to -20 D) and 6mm (-5 D to -20 D) sizes, in 1D increments.

 

Q  What are the indications for this lens?

A  Implantation of a Verisyse Phakic IOL is one option for nearsighted (myopic) patients seeking refractive surgery to reduce or eliminate their dependence on eyeglasses or contact lenses.

 

Q  How is the Verisyse lens implanted, and is it permanent?

A  The patient’s natural lens remains in the eye.  The Verisyse is surgically implanted in front of the patient’s natural lens, between the cornea and the iris.  Surgery is performed on one eye at a time, with the second eye commonly scheduled within 3 months of the first eye.

This, and other lens implant procedures, is considered permanent.  However, should it become necessary to remove the lens, it can be accomplished with a subsequent surgical procedure.  Should this occur, it is possible for the best-corrected vision to be reduced from the pre-surgical state.

 

Q  What codes are used to describe this procedure?

A  Effective April 1, 2012, use HCPCS code S0596, Phakic intraocular lens for correction of refractive error, to describe this procedure.  Medicare and a few other payers do not accept HCPCS codes beginning with “S”, so a miscellaneous code (66999) is used instead.

In either case, the same code identifies the facility fee for the hospital or ASC.  HCPCS code V2631, Iris supported intraocular lens, identifies the IOL.

 

Q  Is the procedure covered by Medicare?

A  No.  While Medicare sometimes covers procedures billed with miscellaneous codes, coverage is not extended to procedures performed solely for refractive purposes.

 

Q  Will commercial insurance cover this procedure and its associated costs?

A  Not usually; refractive surgery is rarely a covered benefit.  Generally, if the payer allows coverage for the surgical procedure, coverage extends to the required preoperative testing and the associated facility fee.  However, if the surgical procedure is excluded from coverage, no payment is made for the associated services, either.

 

Q  What charges are associated with this procedure?

A  Patients can expect several separate charges:  some preoperative testing, the surgeon’s professional fee, a facility fee for the operating room and associated costs, and a charge for the lens.  There is also an anesthetist’s fee as well in some cases, as well.

 

Q  How do the practice and the ASC collect payment from the patient without violating their agreements with payers?

A  Both Medicare and commercial insurers have limitations of coverage.  When patients seek services that are non-covered under their plans, they must be informed of their financial responsibility in advance.  This is accomplished by obtaining the patient’s signature on a Notice of Exclusion from Medicare Benefits (NEMB) for Medicare patients, or Notice of Exclusion from Health Plan Benefits (NEHB) for other payers.

For sample forms, please visit our web site and download the Verisyse Phakic IOL Forms.

You are not required to submit claims for statutorily non-covered services unless specifically requested to do so by the patient.  If you do submit a claim, be sure to include modifier GY and use a refractive diagnosis.

 

Q  What if there is a complication; would treatment be covered by insurance?

A  Usually.  Treatment provided to address complications (e.g., infection, ocular hemorrhage, lens dislocation) is considered medically necessary care, even if the original procedure is refractive.  Some third party payers take a different position and do not cover complications of non-covered, cosmetic procedures; check the payer policy.

 

Provided Courtesy of Abbott Medical Optics (877) 466-4543

 

Last updated April 12, 2012

 

The reader is strongly encouraged to review federal and state laws, regulations and official instructions promulgated by Medicare and other payers.  This document is not an official source nor is it a complete guide on all matters pertaining to reimbursement.  The reader is also reminded that this information, including references and hyperlinks, can and does change over time, and may be incorrect at any time following publication.

 

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