Eyeworld

EW CATARACT 42 July 2014 Misconception #3: Cataract patients with astigmatism can pay for "laser cataract surgery." The term "laser cataract surgery" does not speak to the patient's astigmatism. It can be misleading because it sounds like only one service, i.e., cataract surgery. So while astigmatism correction is a service for which the patient can be charged, be thoughtful about how you describe it when it is combined with a cataract procedure. When using a laser to create an arcuate cut on a cataract patient, there are two services being provided: cataract surgery and astigmatism correction. An arcuate cut can be included in the charge to the patient for the service of astigmatism correction, but that charge should be displayed in a way that clearly distinguishes it from the bill for cataract surgery. It is advisable to obtain separate in- formed consent for each procedure. This practice also helps patients to understand the two procedures are different. Misconception #4: If a facility is already charging the patient for providing an ATIOL, an additional charge for the laser is not permitted. An additional charge for just the imaging technology and work is permitted by the CMS guidance. In our view, it's better to fold the imaging charge into a comprehen- sive facility charge for presbyopia correction or astigmatism correc- tion. Patients often get confused when too many a la carte pricing elements are presented on the bill, which is probably why cosmetic surgeons typically don't bill for individual technologies or supplies used in a noncovered service. In- stead, they just bill for the service being provided, e.g., blepharoplasty. Misconception #5: Upon acquiring a laser, a facility may increase its charges for correcting presbyopia or astigmatism with an ATIOL, and the charge for the imaging function must be listed separately. The CMS guidance states that the ATIOL charges "could possibly include charges for additional services, such as imaging." Note that there is no requirement to break out a charge for laser imaging separately, and we believe doing so is not neces- sary. It may be clearer for patients if they are simply billed a single facil- ity charge for the service of presby- opia correction or astigmatism correction. Imaging can be taken into consideration when providers set fees for those services. The facil- ity's cost of providing those services includes the incremental cost of the ATIOL (as compared to a monofocal IOL) as well as a per-procedure allocation of the laser's imaging function. The cost item underlying the surgeon's charge is his/her extra work beyond what is done for cataract surgery with a conventional IOL, which would include utiliza- tion of imaging with the laser. Misconception #6: With a femtosecond laser, the only non-covered service that can be charged to the patient is astigmatism correction. Both astigmatism correction and presbyopia correction are services that are not covered in the Medicare program. Femtosecond lasers offer two approaches for correcting astig- matism: (1) an arcuate cut with or without IOL implantation, and (2) precise positioning of an astigma- tism-correcting IOL enabled by im- aging. The patient can be charged for the noncovered service regardless of which technology or approach is used to provide it. Identically, patients can be charged for the noncovered service of presbyopia correction with an ATIOL, and the charge may include use of the imaging function of a femtosecond laser system. Misconception #7: Imaging is part of the cataract functionality of a femtosecond laser. As was explained by industry to CMS, imaging is not necessary for a femtosecond laser beam to be able to cut capsule, incise the cornea, or break up nuclei. A point-and-shoot approach could be used wherein the surgeon directs the beam manually. The degree of precision is helpful for the noncovered aspect of ATIOLs to perform as intended because even small misalignments can prevent them from delivering on the prom- ise of spectacle independence. In contrast, this same degree of minor IOL misalignment does not hinder a monofocal IOL's ability to correct aphakia, which is one of the purposes of a conventional IOL. Misconception #8: You can't price an ATIOL higher just because you used a femtosecond laser for cataract surgery. If a provider increases his or her charge for refractive correction with an ATIOL after acquiring a femtosec- ond laser, the increase is attributable to the use of imaging on the laser. It is not attributable to the ATIOL. In the refractive market, providers set prices based on their costs and com- petitive forces. To the extent that imaging increases the cost of provid- ing the refractive service, correspon- ding price increases are allowed, and the market will decide whether it wants to pay the higher price. In- stead of listing a charge for the non- covered aspect of the ATIOL and a separate charge for imaging on a femtosecond laser, consider a single facility charge for the service being provided: astigmatism correction or presbyopia correction. Your price for these services can take into account the incremental cost of an ATIOL and the cost of imaging on a fem- tosecond laser. If your local market will bear it, that price can be higher than what you charged without laser-based imaging. Misconception #9: The laser cannot be offered unless the patient has astigmatism. Medicare covers cataract surgery with or without the laser. It's not required that patients have astigma- tism or presbyopia for the laser to be used to treat their cataracts. However, it is very important to understand a critical stipulation in the CMS guidance pertaining to the laser's imaging function. If a provider uses imaging "routinely" to perform cataract surgery with a conventional IOL, then imaging is deemed part of that provider's stan- dard surgical protocol for cataract surgery; thus, he or she cannot include imaging in the charge to ATIOL patients for the noncovered service. "Routinely" is not quantita- tively defined by CMS, so we advise careful consideration of whether to use the imaging function of the laser on a substantial portion of cataract cases that do not involve an ATIOL or an arcuate cut. Note that when a laser-based arcuate cut is performed, the imaging function is required to determine the placement of the ar- cuate cut. In that context, imaging is a step of astigmatism correction and not a step of cataract surgery. Thus, that use of imaging would not factor into the calculation of "routinely." Misperception #10: Some of my patients with complex cataracts could benefit from the use of a femtosecond during cataract surgery, but if I use it on those patients I will no longer be able to charge ATIOL patients for imaging. The ethical dilemma inherent in this question is resolved by the term "non-routine" in the CMS guidance: "If the bladeless, computer con- trolled laser cataract surgery includes implantation of a PC-IOL or AC-IOL, only charges for those non-covered services specified above may be charged to the beneficiary. These charges could possibly include charges for additional services, such as imaging, necessary to implant a PC-IOL or an AC-IOL but that are not performed when a conventional IOL is implanted. Performance of such additional services by a physi- cian on a limited and non-routine basis in conventional IOL cataract surgery would not disqualify such services as non-covered services." Providers may use imaging on a non-routine basis without the risk of it being deemed a part of that provider's normal cataract surgery protocol. CMS does not define what percentage of cataract cases would constitute "routine" use, leaving it open to interpretation. Common sense is advised. EW Editors' note: Dr. Lane is clinical professor of ophthalmology at the University of Minnesota, Minneapolis. He has financial interests with Alcon (Fort Worth, Texas). Ms. Weber Shuren is a partner at Arnold & Porter LLP, Washington, D.C. Contact information Lane: sslane@associatedeyecare.com Weber Shuren: allison.shuren@aporter.com Dispelling misconceptions continued from page 40 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 relative to the visual axis—a degree of precision not required for successful outcomes with conventional IOLs. 38-42 Cataract_EW July 2014-DL_Layout 1 6/26/14 4:09 PM Page 42

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