Refractive cataract surgery coverage

Ensure that your patients know what’s covered — and what isn’t.

In most situations, coding for cataract surgery with an IOL is relatively straightforward. You usually need to consider two common codes: CPT 66984 for “standard” surgery and CPT 66982 for more complex surgery. Coverage and payment are based on meeting the payer’s guidance, which commonly involves documenting patient lifestyle problems (often known as “activities of daily living,” or ADL) that arise from the cataract and other factors such as best-corrected acuity, the need to see the retina, and a few other less common reasons.

When coverage exists

The payer covers the cataract removal and standard intraocular lens (IOL) implantation if the policies and rules are followed. Other generally covered items associated with cataract/IOL surgery:

  • Exam or consultation
  • Pre-operative discussion (consent, scheduling time, refractive options)
  • All biometry and IOL calculations (even if a post-refractive cornea is involved)
  • The “global 90-day postoperative period”
  • Conventional IOL itself
  • Facility fee for the surgery center or hospital
  • Anesthesia

When the patient is responsible

In today’s environment in which toric or presbyopia-correcting IOL implantation and corneal surgery for astigmatism occur in tandem with the cataract surgery, the payer is not likely to cover a refractive component. In this case, the patient is generally fully responsible to pay the surgeon and facility.

The noncovered items that might occur at some point include some of the following:

  • Refraction (never a Medicare benefit)
  • Screening tests for suitability (such as OCT looking for epiretinal membrane or corneal topography for regular astigmatism)
  • Refractive surgery (corneal astigmatism surgery)
  • IOL upgrade cost over the basic payment (presbyopic or toric IOLs)
  • Added facility fee (things that don’t happen in standard cataract surgery)
  • Extended postop care (sometimes offered beyond the 90-day global period)

Notice that we’re not talking about shifting an 8D myope or a 2D hyperope to plano; that’s part of normally covered cataract surgery. Likewise, adjusting the IOL powers for a blended or monovision result isn’t billable to the patient or insurance (except for some specialized noncovered testing in advance if performed, such as a contact lens trial). Table 1 may help clarify this idea for the surgical portion.

Table 1. Surgical reimbursement grid
Covered Cataract surgery Cataract surgery
Noncovered Deluxe IOL component
Limbal-relaxing incision (LRI) or
corneal-relaxing incision (CRI)
Refractive care

Medicare, in CMS Rulings 05-01 on presbyopic IOLs and 1536-R on toric IOLs, noted the following:

  • “A single presbyopia-correcting IOL essentially provides what is otherwise achieved by two separate items: an implantable conventional IOL (one that is not presbyopia-correcting), and eyeglasses or contact lenses.
  • “… In some cases, a single IOL that also corrects pre-existing astigmatism may provide what is otherwise achieved by two separate items: the implantable conventional IOL that is covered by Medicare and the surgical correction, eyeglasses, or contact lenses for treatment of pre-existing astigmatism that are not covered by Medicare …”
  • “… the facility and physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring … that exceeds the work and resources attributable to insertion of a conventional IOL”
  • “… the beneficiary requests this service”
  • “The physician and the facility may not require the beneficiary to request a … [special] correcting IOL as a condition of [surgery]”

Essentially, this means that the “basic IOL” is a covered service payable by Medicare, and the “upgraded” version, which adds to the basic IOL power and corrects astigmatism or presbyopia, is noncovered.

Corneal refractive surgery when no other eye surgery has come before is wholly a refractive service. Medicare does not cover LASIK or PRK, and this is no different. Most often this is done using either a blade or a femtosecond laser. (We covered the use of the femtosecond laser on cataract surgery and the related billing and coding in previous OP Coding columns: , .)

Patient discussions

Be transparent with patients and family before surgery about what is and is not covered since payment may affect their decision process. Your office already does a surgical consent to show the benefits and possible risks of cataract surgery, which would include the offer of a choice for additional refractive surgery if beneficial, so think of this part of the explanation as similar in intent.

For Medicare, the Advance Beneficiary Notice is used to do this ( ); other payers use similar documents, but be sure and check.

As always, “good coding to you.” OP