EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78719
February 2012 Ophthalmology groups provide guidance for billing for femtosecond laser use www.AcrySofReSTOR.com Background on the ASCRS- AAO joint advisory on femtosecond laser billing guidelines for Medicare cataract patients by David F. Chang, M.D., ASCRS president-elect O n January 30, ASCRS and AAO jointly issued a member advisory docu- ment to provide current guidelines for billing Medicare beneficiaries when using the femtosecond (FS) laser at the time of cataract surgery. Although the technology has generated great interest and excitement among oph- thalmologists, there have been nu- merous questions and concerns about whether and when it is per- missible to bill Medicare patients for using this technology. As a result of LenSx (Alcon, Fort Worth, Texas) systems being actively marketed and sold in the U.S., the leadership of ASCRS and AAO recog- nized that ophthalmologists are in a difficult position of trying to make major financial and strategic deci- sions without being sure of when and which patients can be billed for the services. Being misinformed about this creates liability and finan- cial risk for individual practitioners and ASCs, and collateral risks for the interests and reputation of our pro- fession as a whole. As a result, the two societies have collaborated in trying to determine what the legal safe harbors are for FS laser reim- bursement in association with cataract surgery for Medicare beneficiaries. This informational document, developed by the two societies over the past several months, provides the most current regulatory guid- ance as of January 2012. Along with our director of government rela- tions, Nancey McCann, I was the ASCRS physician representative to the work group that included AAO medical director of health policy, William Rich, and AAO medical director for governmental affairs, Michael Repka. The ASCRS Executive Committee was actively involved throughout the entire process. Rec- ognizing the many controversial is- sues surrounding this technology, this was not intended to be a posi- tion paper on the clinical merits of the technology or how it should be reimbursed. The goal was to provide the best reimbursement guidance continued on page 83 © 2011 Novartis 8/11 RES11067JAD CAUTION: Federal (USA) law restricts this device to the sale by or on the order of a physician. INDICATIONS: The AcrySof® Guidelines for billing Medicare beneficiaries when using the femtosecond laser The allowable Medicare reimbursement for cataract surgery does not change according to the surgical methods used. For example, the reimbursement is the same whether a cystotome or femtosecond (FS) laser makes the capsulotomy. Providers may not "bal- ance bill" a Medicare patient or his or her secondary insurer for any additional fees to perform covered components of cataract surgery with an FS laser. Medicare Part B permits patients to be billed for additional services used specifi- cally to implant premium refractive IOLs (presbyopia-correcting and toric) for medically necessary cataract. The surgeon and facility may charge the patient for premium refrac- tive IOLs (presbyopia-correcting and toric) and the associated incremental professional and technical services. The patient, however, must be informed about and consent to the additional out-of-pocket costs in advance. Refractive lens exchange A refractive lens exchange is not medically necessary and therefore is not covered under Medicare Part B. The surgeon and the facility may bill the patient. Tiered pricing is allowed (e.g., additional fee for premium refractive IOL; additional fee to use the FS laser for lens removal steps), subject to properly documented informed consent. Medically necessary cataract extraction with a conventional IOL (no astigmatic keratotomy) Medicare Part B covers the cataract surgery and the implantation of a conventional IOL without regard to the technology used. A surgeon may use the FS laser for the cataract surgery, but neither the surgeon nor the facility may obtain additional reimbursement from either Medicare or the patient over and above the Medicare-allowable amount. Medically necessary cataract extraction with a premium refractive IOL (no astigmatic keratotomy) Neither the surgeon nor the facility should use the differential charge allowed for implan- tation of a premium refractive IOL to recover all or a portion of the costs of using the FS laser for cataract surgical steps. As set forth above, Medicare Part B covers the cataract surgery and the implantation of a conventional lens without regard to the technology used. Patient-shared pricing with one cost for a premium IOL and a higher cost for the additional use of the FS laser to perform the cataract surgical steps should not be of- fered. This would amount to charging the patient to use the FS laser to perform covered components of the procedure. Medically necessary cataract surgery plus astigmatic keratotomy performed for refractive indications Medicare will cover medically necessary cataract surgery, but not concurrent correction of astigmatism performed for refractive indications. Medicare patients may be charged a fee for performing astigmatic keratotomy, assuming that they were informed about and consented to the non-covered charges in advance. Because astigmatic keratotomy for refractive indications is a non-covered service, a higher fee can be charged for perform- ing it using the FS laser, instead of with a metal or diamond blade. As with premium IOLs, however, the patient should not be charged an additional amount to concurrently perform the cataract surgical steps with the FS laser. While most astigmatism treatment is not covered, Medicare does cover the treatment of large degrees of astigmatism that were the result of previous ocular surgery. Local coverage determinations may apply. In this situation, neither the surgeon nor the facility may obtain additional reimbursement from either Medicare or the patient over and above the Medicare allowable amount. Additional considerations Advertising: Promotional claims must be consistent with the best available clinical evidence and should not be deceptive or misleading to patients. Transparency: Patient-shared pricing should be discussed openly with the patient. Increased charges should be explained and documented. Note: The guidelines presented in this advisory represent the best effort of AAO and ASCRS, as of January 2012, to determine when Medicare and its beneficiaries can be billed for using the femtosecond laser during cataract surgery. They are subject to modi- fication based on any new regulations issued by the Centers for Medicare and Medicaid Services or its contractors. The organizations suggest that ophthalmologists seek addi- tional guidance directly from their Medicare carriers for coverage determinations under Medicare Part C or through commercial carriers. IQ ReSTOR® Posterior Chamber Intraocular Lens (IOL) is intended for primary implantation for the visual correction of aphakia second- ary to removal of a cataractous lens in adult patients with and without presby- opia, who desire near, intermediate and distance vision with increased spectacle independence. The lens is intended to be placed in the capsular bag. WARNING/PRECAUTION: Careful pre- operative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient with any of the conditions described in the Direc- tions for Use labeling. Physicians should target emmetropia, and ensure that IOL centration is achieved. Care should be taken to remove viscoelastic from the eye at the close of surgery. Some patients may experience visual disturbances and/or discomfort due to multifocality, especially under dim light conditions. Clinical studies with the Ac- rySof® ReSTOR® lens indicated that pos- terior capsule opacification (PCO), when present, developed earlier into clinically significant PCO. Prior to surgery, physi- cians should provide prospective pa- tients with a copy of the Patient Informa- tion Brochure available from Alcon for this product informing them of possible risks and benefits associated with the AcrySof® IQ ReSTOR® IOLs. Studies have shown that color vision dis- crimination is not adversely affected in individuals with the AcrySof® Natural IOL and normal color vision. The effect on vi- sion of the AcrySof® Natural IOL in sub- jects with hereditary color vision defects and acquired color vision defects sec- ondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize; do not store over 45° C; use only sterile ir- rigating solutions such as BSS® PLUS® or BSS Sterile Intraocular Irrigating Solu- tions. ATTENTION: Reference the Directions for Use labeling for a complete listing of in- dications, warnings and precautions.