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EW CATARACT 40 July 2014 by Stephen Lane, MD, and Allison Weber Shuren, MSN, JD Dispelling misconceptions Experts discuss the CMS rulings for advanced technology IOLs and the CMS guidance for femtosecond lasers C MS issued the rulings for presbyopia-correcting IOLs (PCIOLs) and astig- matism-correcting IOLs (ACIOLs) in 2005 and 2007, respectively. The rulings estab- lished that each of the two classes of IOLs bears two aspects: one that relates to a covered service (cataract surgery) and another that relates to a service that is not covered (presbyopia correction or astigma- tism correction). In 2012, femtosecond lasers were introduced offering functional- ity for both cataract surgery as well as correction of presbyopia and astigmatism. Misworded advertise- ments about laser cataract surgery caused CMS to become concerned that patients were being charged for use of the laser in cataract surgery. In response, the laser industry worked with CMS to distinguish the functions of femtosecond lasers that are utilized for cataract surgery. The guidance released by CMS on November 16, 2012, reflected the laser industry's work to clarify that the imaging function of the laser systems is designed to enable highly precise placement of an ATIOL rela- tive to the visual axis—a degree of precision not required for successful outcomes with conventional IOLs. The resulting guidance from CMS acknowledged that imaging is a function of laser systems that can be included in charges to cataract patients who choose ATIOLs. In contrast, laser-created capsulotomy, primary incision, and nuclear frag- mentation were acknowledged by both CMS and industry as steps of cataract surgery and thus not sepa- rately billable in any circumstance. Below we address some miscon- ceptions pertaining to what can and cannot be charged to patients when ATIOLs and femtosecond lasers are used to perform cataract surgery and a noncovered service in the same surgical session. Misconception #1: Providers can charge cataract patients for "laser cataract surgery." The term "laser cataract surgery" can be misleading to patients be- cause it sounds like the only service being provided is cataract surgery when in fact there are two services being provided: cataract surgery and refractive surgery (presbyopia correction or astigmatism correc- tion). Providers can charge cataract patients only when a noncovered service such as astigmatism correc- tion with arcuate cuts made by a femtosecond laser, or ATIOL surgery with a femtosecond laser, is also being provided, in which case the charge is for the noncovered service, not for cataract surgery. Misconception #2: The femtosecond laser charge and the ATIOL charge should be billed separately to the patient. The CMS guidance allows that when an ATIOL is implanted the charges for correcting astigmatism or presbyopia could include the use of imaging on a femtosecond laser system. Rather than show a separate line item on the bill for use of the laser, surgeons and facilities may set a single charge for the service being provided, not for individual surgical steps or items such as a laser beam. ATIOL patients essentially receive two services: cataract surgery (cov- ered) and refractive surgery (not covered). Femtosecond lasers offer functions for both services. Surgeons and facilities may choose to increase their fees for correcting presbyopia or astigmatism due to the extra cost and benefits of using imaging with a femtosecond laser, and it must be clear that the resulting fee is not related to treating the cataract. educating the consumer about their potential purchase options and choices so that they can be a more informed buyer and ultimately make a purchase that serves them best. The car salesperson's role at this point is NOT selling but is one of educating the buyer about potential choices and answering any questions. This educational process is extremely important to empower the purchaser by letting them know what different features are available. Imagine if you bought a car and after driving it off the dealership lot discovered there was an option to purchase the same vehicle but with heated seats, separate climate control for passengers and driver, a remote starter, or any other acces- sory or feature that you would find desirable yet didn't know about at the time you committed to your purchase. You wouldn't be happy and you certainly wouldn't consider the person you had worked with to be a good car salesperson. This would not have anything to do with the cost of the vehicle and everything to do with a poor educational process at the dealer- ship. It's likely on this basis alone that you would tell others not to use the dealership. The relevance of the above to educating patients about cataract surgery options should be obvious. It is clearly the ophthalmologist's responsibility to let patients know about what choices they have when considering cataract surgery. Describing the different choices that patients have at the time of cataract surgery is NOT selling— it is educating the patient and vitally important. From the above it is clear that the car salesperson performs a help- ful and useful function by educating the consumer about the different features and options of the vehicle they are purchasing. No one would consider this in a negative fashion. Why then do car salespeople have such a poor reputation? I believe it has nothing to do with this educational process but instead is An apology continued from page 39 continued on page 42 related to what happens during the negotiating of the purchase price of the vehicle. In part two of this article "Putting the cart before the horse: Educating vs. selling," I'll review how to avoid all the negative aspects of "selling" by focusing on educat- ing patients about their options. EW Editors' note: Dr. Tipperman is affiliated with the Wills Eye Institute, Philadelphia. He has no financial interests related to this article. Contact information Tipperman: rtipperman@mindspring.com 38-42 Cataract_EW July 2014-DL_Layout 1 6/26/14 4:09 PM Page 40

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