Excerpted from page 44 of the March 2018 edition of AOA Focus.
AOA's coding experts frequently receive questions regarding the appropriate coding for postoperative glasses. Here's what you need to know:
Coverage
Medicare will cover one pair of eyeglasses or contact lenses as a prosthetic device furnished after each cataract surgery with insertion of an intraocular lens (IOL). Replacement frames, eyeglass lenses and contact lenses are noncovered.
Frequency
Medicare will pay for one pair of post-cataract surgery glasses per lifetime per eye after cataract surgery. You also should review any local coverage determinations (LCDs) to find out if there are any local policy stipulations. Additionally, you also may want to call the Durable Medical Equipment Regional Carrier for your area to see if the patient is presently eligible for the glasses. Some LCDs clarify, "If a beneficiary has a cataract extraction with IOL insertion in one eye, subsequently has a cataract extraction with IOL insertion in the other eye, and does not receive eyeglasses or contact lenses between the two surgical procedures, Medicare covers only one pair of eyeglasses or contact lenses after the second surgery. If a beneficiary has a pair of eyeglasses, has a cataract extraction with IOL insertion, and receives only new lenses but not new frames after the surgery, the benefit would not cover new frames at a later date (unless it follows subsequent cataract extraction in the other eye)."
Diagnoses to report
Payable diagnosis codes include:
- Z96.1 (pseudophakia)
- H27.01, H27.02, H27.03 (aphakia)
- Q12.3 (congenital aphakia)
CPT codes to report
For one or two lenses, bill the correct Healthcare Common Procedure Coding System code (V21xx, V22xx, or V23xx) on separate lines for each eye; use modifier RT or LT and the fee for one lens at your standard fee.
Claims submission
If you are billing for eyeglasses or contact lenses, you should submit claims to your Medicare Durable Medical Equipment Administrative Contractor (DME MAC). Find a list of DME MACs.
Fees for DME suppliers
All suppliers of Durable Medical Equipment, Orthotics and Prosthetics (DMEPOS), including eyeglasses and contact lenses for postoperative cataract patients, are subject to an enrollment and revalidation fee. The AOA continues to advocate with the Centers for Medicare & Medicaid Services so that doctors who are enrolled in Medicare as physicians should be exempt from this fee.
To stay abreast of code changes and the latest coding information, access the AOA's coding resources:
- Online resources. For up-to-date codes and resources, access AOA's coding information at aoa.org/coding and AOA Coding Today.
- Got a coding question? If you have specific coding questions that are not addressed through AOA Coding Today, direct them to AOA's Coding Experts by completing the online form.
- Reference manuals. Purchase the 2018 CPT code bundle at AOA Marketplace.
If you have suggestions on how the AOA can best support the coding needs of doctors of optometry, please contact Kara Webb, AOA's associate director for coding and regulatory policy, by email or call 703.837.1018.
Medicare is designed to provide health insurance to adults 65 years of age and older, for young people with specific disabilities, and for patients who need a kidney transplant or dialysis for end-stage kidney disease. Most people covered by Medicare in their 60s and older, the target age for the development of cataracts. In these cases, Medicare will cover the cost of diagnosis of and treatment for cataracts.
Since 1992, Medicare has had a ‘’global surgery package’’ covering cataract surgery as a necessary medical procedure. Crucial components covered in all cataract surgeries include:
- Preoperative care
- Postsurgical care for a maximum of 90 days
- Intraoperative aspects like anesthesia
- In-office care for complications arising from surgery
When undergoing cataract surgery, you have multiple alternatives for the intraocular lens, an artificial lens that replaces your diseased lens. Medicare, however, only pays for monofocal lenses plus contact lenses or glasses, which help you focus your vision after the surgery.
If you choose a different lens, Medicare will only cover costs up to the price of the monofocal lenses. You will have to pay the difference in price. Eye doctors have a number of older patients, and the office staff in charge of billing can answer questions about how they will bill Medicare for your surgery and what kind of costs you will be responsible for in the end.
If you qualify for Medicare and need cataract surgery, learn more about how Medicare covers your costs and how you can work with the program to get newer procedures.
Cataract Surgery Is Considered Medically Necessary
Cataracts are a disease of the lens in the eye, which is the organ behind the pupil that refracts light onto the retina, so the brain can process images of the world around you. There are several diseases that can affect the lens and therefore impact vision. Cataracts are one of the conditions that can lead to blindness over time.
This condition starts when proteins in the lens break down, leading to blurring or clouding of your vision. Damaged proteins will clump together in specific formations leading to loss of sight. You may also experience double vision, yellowing or fading vision, or cloudy spots in your line of sight.
Although many people develop cataracts because of an injury, disease, or congenital defect, most cataracts occur due to age. Everyone’s vision changes as they get older, but over the age of 40, cataracts become increasingly likely. After middle age, you may develop cataracts in one or both eyes.
The majority of cataracts that begin in middle age are small and do not affect your vision for many years. Most people do not experience serious problems driving, seeing objects, or performing activities until they are in their 60s.
Since cataracts affect older and elderly adults, it is important to know how insurance, especially Medicare, covers this condition. Although the federal health insurance program does not cover most vision issues, cataract removal is covered.
How Medicare Works With Cataract Surgery
Overall, cataracts are considered serious medical issues by health insurers, hence they cover most of the treatment costs. Medicare will cover expenses related to basic management of cataracts, including the removal of lenses and replacement with an artificial one.
Medicare comprises different parts, which cover various services. These include:
- Part A, which covers inpatient programs like stays in skilled nursing facilities and hospitals.
- Part B, which covers some elements of outpatient care, doctors’ services, and preventive care.
- Part C (the Medicare Advantage Program), which allows patients to pick an extra private insurance plan, covering ailments that might not be fully covered under the federal program.
- Part D, which covers prescription drugs.
Most Medicare recipients get most of their conditions covered by Parts A, B, and D. Since Part C was added, Medicare-approved health insurance programs are more easily available to older adults who need additional coverage for their medical conditions or want added levels of care beyond the basic coverage for procedures like cataract surgery.
Since cataracts can impact your safety and quality of life, they are considered a medically necessary procedure, so Medicare will cover much of the cost of the surgery. While the program does not typically cover vision problems, cataracts lead to problems beyond just fuzzy vision. When untreated, they can lead to blindness.
Technological improvements have added enhancements to cataract surgery, but the basic procedure involves:
- Local anesthetic to the eye.
- Removal of the diseased lens.
- Monofocal lens implant.
- Prescription eye drops to prevent infection.
- Checkups after the procedure to ensure the eye heals properly.
- Reading glasses or contact lenses to adjust vision beyond single focus.
The basic cataract removal surgery itself involves a blade called the microkeratome, which makes an incision in the cornea and then in the lens, allowing another device like a small probe or laser to access the lens, soften and break up the diseased parts, and remove them. Then, the artificial lens is inserted through the incisions, which are self-sealing and very rarely require stitches.
There are other, more modern approaches to cataract surgery including bladeless or all-laser surgery, but adding additional new devices like lasers to the procedure can add higher costs, and these costs are not likely to be covered by Medicare. Increasingly, however, laser-assisted cataract surgery is being covered by Medicare and other insurance programs, often giving patients heightened safety and reduced healing time.
The monofocal lens is the basic intraocular lens (IOL) implant. This is a small, clear disk that replaces the biological lens in your eye after it has developed serious cataracts. This lens is considered medically necessary, and the implant is covered by Medicare; however, there are other types of lenses, called premium lenses, which allow for different ranges of vision without corrective wear like glasses. These are not covered by Medicare, as they are not considered medically necessary.
As a patient, you can ask for bladeless cataract surgery and multifocal lenses if you want, but it is important to know that Medicare and your secondary insurance are not as likely to cover these costs. Instead, you will pay for these upgrades out of pocket.
How to Determine What Costs Medicare Will Cover
- Ask your eye doctor, surgeon, or hospital about the specific costs of surgery and postoperative care.
- Determine if you will need inpatient or outpatient care since they are covered by different Parts. Cataract surgery is typically outpatient care, but there are rare instances when an overnight stay in the hospital may be required.
- Check with your other insurance programs, through Part C or otherwise, if they cover any aspects of cataract surgery.
- Check your Part A deductible.
- Check your Part B deductible because this part covers one pair of glasses or set of contact lenses to help your vision after cataract surgery in addition to other outpatient costs.
Medicare rulings state that patients are generally charged for portions of services that are not covered by the federal healthcare program. In the case of cataract surgery, this most often involves upgrades to the IOL.
In 2005, Medicare allowed beneficiaries to pay additional charges for a presbyopia-correcting intraocular lens (PC-IOL); in 2007, a ruling determined that beneficiaries should pay the cost of an astigmatism-correcting intraocular lens (AC-IOL). Both astigmatism and presbyopia are refractive errors. Astigmatism is a problem with the shape of the lens, leading to difficulty focusing, while presbyopia is an age-related change to the shape of the lens leading to farsightedness. While both of these conditions can lead to vision issues, they are not associated with increased risk of cataracts. Replacing the lens of the eye with an artificial lens, or undergoing surgery like LASIK to correct these errors, is not considered medically necessary under the federal government’s guidelines.
In the 2012 press release from the Centers for Medicaid & Medicare Services (CMS), the federal program states that laser-assisted or bladeless cataract surgery would be covered by the program, and other insurance companies may decide as they wish. The main cost of the surgery that is not covered by Medicare is a premium IOL.
It is important to know that Medicare funds are managed at the state level, so the amount of coverage for bladeless cataract surgery could be different in different states. If you have questions about this cost, it is important to speak with your ophthalmologist and eye surgeon before proceeding.
As of 2017, the cost of cataract surgery without any insurance coverage was between $3,600 and $6,000 per eye. This depends greatly on your geographical location, how much testing occurs before you go into surgery, any medical issues you have (like glaucoma or diabetes) that can impact surgery length and hospital stay, and how many upgrades to the procedure you choose. Medicare will cover the basics of the preoperative testing, surgery, implant, and postoperative care, but it will not cover additional issues.
FAQs about Medicare Coverage for Cataract Surgery
Why won’t Medicare cover all items and services related to cataract surgery?
The Social Security Act limits what is covered by Medicare. The insurance will not pay for everything you need, even when the doctor certifies them as necessary as per the regulations of the Medicare Act.
What will you pay for cataract surgery in ASCs (ambulatory surgery centers)?
In an ASC, you will pay for the difference between the amount that Medicare pays for standard cataract surgery and the extra cost for your IOL plus a handling fee. Some ASCs also charge a usage fee for the aberrometer when using premium IOLs. Exact costs are difficult to quantify. Cataract procedures are almost always outpatient procedures, which keeps the cost down.
Will Medicare coverage differ for laser and bladeless surgical procedures?
No. Medicare payment and coverage are similar, whether your cataract surgery is done using a computer-controlled laser or the conventional blade. In both instances, Medicare meets the expenses of cataract removal and implantation of an IOL.
Will Medicare cover the cost of eye exams, glasses, or contact lenses after surgery?
No. Medicare does not cover any routine eye exams for glasses or contacts. It is possible to qualify for some exam coverage under Medicare Part C, but that will depend on your particular situation.
Are there any other programs that can help me cover the cost of cataract surgery?
Yes, there are. Mission Cataract USA offers free cataract surgery to people of all ages who can’t afford the procedure. In addition, Operation Sight also provides financial assistance for eye patients with low incomes.
Financing Your Cataract Surgery
Typically, cataract surgery is covered by insurance and Medicare. However, in the event that your procedure is not fully covered, or if you elect to choose an upgraded lens option as part of your treatment plan, NVISION® offers financing options to ensure that you are not inhibited by cost. Read on to learn more about CareCredit® and see how cataract surgery can be affordable.
Learn More about Financing Your Cataract Surgery
References
What Are Cataracts? (November 9, 2018). American Academy of Ophthalmology (AAO).
Facts About Cataract. (September 2015). National Eye Institute (NEI).
Cataract Surgery. Medicare.gov.
What’s Medicare? Medicare.gov.
What Is Medicare Part C? (August 11, 2014). U.S. Department of Health and Human Services (HHS).
Cataract Surgery. (November 9, 2018). American Academy of Ophthalmology (AAO).
Traditional Cataract Surgery vs. Laser-Assisted Cataract Surgery. (August 10, 2017). American Academy of Ophthalmology (AAO).
IOL Implants: Lens Replacement After Cataracts. (May 25, 2018). American Academy of Ophthalmology (AAO).
Laser-Assisted Cataract Surgery and CMS Rulings 05-01 and 1536-R. (November 16, 2012). Center for Medicare & Medicaid Services (CMS).
Refractive Errors Defined. (October 2010). National Eye Institute (NEI).
Cataract Surgery Cost. (August 20, 2018). All About Vision.
Premium IOLs – A Legal and Ethical Guide to Billing Medicare Beneficiaries. (October 2018). EyeNew Magazine.
Surgery. (July 2021). Medicare.gov.
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