February 15, 2007
3 min read

Documentation critical in billing for presbyopia-correcting IOLs

Functional status of the patient helps determine a procedure’s medical necessity, consultant says.

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Spotlight on Lens-Based Refractive Surgery

Proper documentation is critical when billing Medicare for cataract surgery with presbyopia-correcting IOLs, according to one Medicare expert.

Riva Lee Asbell, an ophthalmic reimbursement consultant, discussed Medicare reimbursement for cataract surgery with presbyopia-correcting IOLs during a sesson on incorporating presbyopia-correcting IOLs into your practice, held during the OSN New York Symposium.

Medicare covers cataract removal with insertion of an IOL and one pair of contact lenses or glasses after surgery. Medicare does not cover the extra expense for a presbyopia-correcting IOL or the additional work involved in the diagnostic workup necessary to select the correct presbyopia-correcting IOL for a patient.

“Preoperatively, one of the most important things in the documentation is that the patient requests the IOL,” Ms. Asbell said. “So you have to make sure you have that in your chart documentation.”

Documenting daily activity

Ms. Asbell discussed three important documents: Activities of Daily Living (ADL), Notice of Exclusion from Medicare Benefits (NEMB) and Advanced Beneficiary Notice (ABN).

Riva Lee Asbell
Riva Lee Asbell

An NEMB is used for procedures that are statutorily excluded from Medicare coverage. In the case of a presbyopia-correcting IOL it would be used for notifying the patient that he is responsible for payment for the extra costs of the presbyopia-correcting IOL as well as other noncovered services.

An NEMB is different from an ABN, Ms. Asbell said. An ABN is used to inform a patient that he may be responsible for services if Medicare deems them not medically necessary and therefore not covered. One example of when an ABN might be used is the case of blepharoplasty that the physician believes is functional but Medicare may deny as a cosmetic procedure.

The ADL form documents the patient’s difficulties with the level and quality of daily activity, Ms. Asbell said.

“What doctors tend to put in their chart documentation is ‘can’t see well.’ It’s these little phrases that are insufficient because they have nothing to do with ADL. The patient has to express that they cannot do certain things and their lifestyle is being hampered,” she said in a telephone interview with Ocular Surgery News.

Ms. Asbell warned that Medicare audits by the Office of Inspector General could focus on the documentation of ADL.

“If you have not documented that the patient is having a problem with their activities of daily living, then they [Medicare] can say the whole surgery was not medically necessary and demand their money back,” Ms. Asbell said.

“The other important thing is that this applies to facilities as well as physicians,” she said. “In other words, the ASC should have that ADL documentation in their chart as well.”

Ms. Asbell shared documents with OSN that outline the position of Medicare and private insurers toward ADL documentation.

A Local Coverage Determination (LCD) from the Medicare carrier in Pennsylvania details ADL documentation requirements. The patient must have cataract-related impairment of visual function “resulting in documented complaints of decreased ability to carry out activities such as (but not limited to) reading, watching television, driving or meeting occupational expectations,” the document said.

Commercial health insurer Aetna’s subjective criteria for ADL documentation state that cataract removal is medically necessary when a patient perceives his ability to carry out “needed or desired activities” as impaired. The patient must perceive visual disability that affects driving, watching television and performing occupational tasks, compromised near vision and a perception that visual disability causes a loss of independence and income.

Include written orders

Chart documentation should include written orders for all diagnostic tests, Ms. Asbell said at the symposium. She said a busy practitioner neglecting to note a diagnostic test order in a chart could lead to audit results that find the procedure medically unnecessary and forces the physician to refund the money to Medicare.

“Some of us are working harder, not smarter,” she said. “You have to have written orders in your chart documentation.”

In cases that involve presbyopia-correcting IOLs, the beneficiary is responsible for paying the portion of the facility charge that exceeds the facility charge for insertion of a conventional IOL, she said. The ASC costs must be limited to the surgical procedure because Medicare does not recognize other costs related to that procedure as being reimbursable for ASCs, Ms. Asbell said.

For more information:
  • Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology and focuses on regulatory, legislative and practice management topics.