ASCs: Avoid This Common PC/AC IOL Cataract Compliance Risk

If you’re like many ophthalmologists and ophthalmic ASCs that perform cataract surgeries, you routinely take a big compliance risk you don’t even know about.

Medicare guidelines for billing presbyopia-correcting (PC) and astigmatism-correcting (AC) intraocular lenses have been around for quite awhile, but there is some misinformation floating around. That misinformation is steering ophthalmologists and ophthalmic ASCs into risky compliance territory, warned Stephanie Ellis at last year’s ASCA annual meeting. “Some bad information floats around” about premium IOLs these days, Ellis says. Often, it comes from supply reps who mistakenly tell you it’s okay for physicians to be involved with premium lens transactions.

It is not okay. It hasn’t been okay for a long time.

Your ASC must purchase the premium lens and bill the patient for the out-of-pocket costs beyond the $150 that Medicare typically reimburses for standard IOLs. You should not have your practice purchase the lenses nor should the practice bill cataract patients for out-of-pocket premium IOL costs.

Eyes Open: Is your practice closely tied to an ASC because of physician ownership interests? If so, your billing staff needs to be especially careful, Ellis stresses. Have the patient write the check for premium IOL out-of-pocket expenses to the ASC, not the practice.

IOLs that Medicare considers ‘premium’: 

Relevant HCPCS codes include:

  • V2788 for PC IOLs such as CrystaLens, ReStor, and Rezoom
  • V2787 for AC IOLs such as Toric.

Tip: It’s a good idea for the ASC’s coders to append the -GY or -GA modifier to the V-code, Ellis recommends. It indicates the patient has signed the ABN. ABNs aren’t mandatory because Medicare never covers premium IOLs. But an ABN is a good communication tool. It helps the patient understand what he or she owes beyond the $150 for a standard IOL.

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