Coding and billing for services rendered to postsurgical cataract patients continues to raise issues in many optometric offices. Following these simple guidelines should alleviate many issuesand the stress of rejected claims.
Take note: These guidelines refer only to Medicare Part B. Although many insurance carriers follow the same guidelines, some do not. Make certain you contact your local carriers prior to submitting claims to ensure that youre compliant with their guidelines and policies.
Comanagement begins with a formal transfer-of-care letter from the ophthalmic surgeon. This document must remain part of the patients record.
The Centers for Medicare and Medicaid Services (CMS) has determined that the postoperative global period following cataract surgery is 90 days. Also, the CMS-approved reimbursement for the postoperative portion of the cataract surgery is 20%.
So, if youre responsible for the patients care for 45 days, you receive 45/90, or half of the postoperative reimbursement. You should bill for all of the days following the transfer of care, but you cannot submit the claim until youve evaluated the patient at least once.
In submitting the claim, remember a few key rules:
The ophthalmic surgeon must be listed as the referring physician.
The diagnostic code you use needs to be identical to that used by the surgeon.
The date of service should correspond to the date of the surgery.
Use the same surgical CPT procedure code used by the surgeon, but add the -55 modifier to signify that you are rendering the postoperative care.
The number of units billed can vary by carrier, so be aware of your carriers requirements.
During this 90-day global period, you may need to perform additional procedures or services unrelated to the cataract surgical event. For example, the patient may develop conjunctivitis in the other eye. When you submit such a claim, be sure to use the proper modifiers (-24 for a separate evaluation and management [E/M] service, or -79 for a separate procedure during the postoperative period) to alert the system that these services are separate from those covered by the global period. In all cases, make sure that your records clearly document the services billed.
Many patients elect to have cataract surgery on their other eye during the initial 90-day global period. Submit a claim for the postoperative care of the second eye as you did for the first eye, but in addition to the -55 modifier you also need to add modifier -79.
You may also add the -RT and/or -LT modifier since the new CMS-1500 claim form allows up to four modifiers per line.
IOLs for Presbyopia
In May 2005, CMS clarified payment rules for those patients who choose presbyopia-correcting intraocular lenses. This allowed providers to balance bill the patient for non-covered care related to the presbyopic portion of the pre- and postoperative care provided. Patients who choose these lenses are responsible for the additional expenses for services that exceed the charges for conventional IOLs.
These charges are a private financial transaction between you and the patient. However, your charges should directly relate to the documented care you provide. Have the patient complete a Notice of Exclusions from Medicare Benefits (NEMB) form (which is available at www.cms.hhs.gov/BNI/11_FFSNEMBGeneral.asp), so that there is no misunderstanding of what charges are and are not covered by Medicare.
Billing and coding for postoperative cataract care can be challenging. Be sure that you are compliant with each carriers policies and documentation guidelines to assure smooth sailing.
Next month: Coding for keratoconus.
Clinical Coding Committee
~John Rumpakis, O.D., M.B.A., Clinical Coding Editor
~D.C. Dean, O.D.
~David Mills, O.D., M.B.A.
~Laurie Sorrenson, O.D.
~Rebecca Wartman, O.D.