By David I. Geffen, OD, FAAO
April 1, 2015
With our growing elderly population, cataract co-management is an important part of most optometric practices. Understanding how to get profitably reimbursed when providing post-operative care is essential.
KEYS TO SUCCESSFUL CLAIM PAYMENT
• Bill Medicare before the end of the full post-op period (the full 90-day post-op period)
• The patient must be seen at least one time before the OD can bill their portion of the post-op care.
• Global fee is divided into two portions: 80 percent is for pre-op and surgery and 20 percent is for post-op.
• When coding for reimbursement, indicate a doctor, other than the surgeon, is billing for part of the outpatient post-operative care.
• Append to the procedure code that describes the surgical procedure performed that has a 90-day post-op period.
• The claim must show the date of the surgery as the date of service.
• Indicate the date of care assumption and relinquished in Item 19 of the CMS form.
90-Day Post-Op Medicare Requirement
Ninety days of post-operative care is a Medicare requirement for cataract surgery. The fee Medicare pays requires and includes 90 days after the day of surgery. When co-managing patients, the surgeon will turn the patient back to the co-managing doctor, who, by Medicare guidelines, receives 20 percent of the global fee for the post-op period. For premium intra-ocular lenses, the global post-op period is typically longer–usually one year. The co-managing doctor will receive a percent of the fee for the premium lens charges, which are in excess of what Medicare covers.
For conventional cataract surgery, the co-managing doctor can expect to receive about $90 per eye. For premium IOLs, torics and multifocals, the doctor may receive between $400-$600 per eye.
Discuss Premius IOL Options with Patients
ODs can help their cataract patients achieve the best possible outcomes by discussing premium IOLs like multifocal and toric IOLs. You would not fit a spherical soft contact lens on a 2-diopter astigmat, so why not recommend correcting astigmatism for your cataract patients, too?
I tell patients that the details of the fees and insurance particulars will be explained by the support staff at the surgery center. They are better equipped to get into the details, and it keeps the OD focused on discussing medical eyecare. However, when recommending premium IOLs, the OD should mention that they cost substantially more than conventional IOLs.
With health care reform, reimbursements will most likely be decreased further for Medicare-covered surgery, which will put pressure on doctors to utilize more premium products. To prepare, the OD should get more familiar with these premium products–including premium IOLs–and be able to educate their patients about them.
Patient Not Covered for Complications Beyond 90-Day Period
Patients who are beyond the 90-day covered period will be charged customary fees for office visits. Fortunately, very few surgery-related complications in post-op cataract patients are seen after the initial three months.
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