“Dropless” Cataract Surgery & Corneal Tissue – CMS clarification

Date: December 20, 2014

On December 12, 2014, CMS released the January 2015 update to payment policies in the Hospital Outpatient Prospective Payment System (OPPS). Effective January 1, 2015, Transmittal 3150 contains two important payment policies for ophthalmologists.

Corneal Tissue

The transmittal reminds hospitals that corneal tissue is paid on a cost basis with HCPCS code V2785. It states: “We remind hospitals that according to Pub. 100-04, the Medicare Claims Processing Manual, Chapter 4, Section 200.1 – Billing for Corneal Tissue, the corneal tissue is paid on a cost basis and not under the OPPS.”

“Dropless” Cataract Surgery

The interest by ophthalmic surgeons to deliver antibiotic and anti-inflammatory agents during cataract surgery via an injection has grown. The compounded drugs injected are often triamcinolone acetonide combined with moxifloxacin hydrochloride and, in some cases vancomycin, is added to this mix as well. The injection of these drugs intraoperatively mitigates the need for postoperative eye drops – which is attractive to both surgeon and patient. This approach has been coined “dropless” cataract surgery.

Transmittal 3150 provides CMS’s position regarding the reimbursement of the injection and associated drugs. With regards to the injection, it states: “Injections are a part of the ocular surgery and are included as a part of the ocular surgery and the HCPCS code used to report the surgical procedure.”

The instructions continue to describe the issues associated with the compounded drug.

“According to Pub.100-04, the Medicare Claims Processing Manual, Chapter 17, section 90.2, the compounded drug combinations described above and similar drug combinations should be reported with HCPCS code J3490 (Unclassified drugs), regardless of the site of service of the surgery, and are packaged as surgical supplies in both the HOPD and the ASC. Although these drugs are a covered part of the ocular surgery, no separate payment will be made. In addition, these drugs and drug combinations may not be reported with HCPCS code C9399. According to the Medicare Claims Processing Manual, Chapter 30, section 40.3.6, physicians or facilities should not give Advance Beneficiary Notices (ABNs) to beneficiaries for either these drugs or for injection of these drugs because they are fully covered by Medicare. Physicians or facilities are not permitted to charge the patient an extra amount (beyond the standard copayment for the surgical procedure) for these injections or the drugs used in these injections because they are a covered part of the surgical procedure. Also, physicians or facilities cannot circumvent packaged payment in the HOPD or ASC for these drugs by instructing beneficiaries to purchase and bring these drugs to the facility for administration.”

The key points clearly stated in this portion of the transmittal indicate:

1. The injection is bundled and not separately reimbursed.

2. The compounded drug is included in the facility reimbursement and no separate reimbursement exists.

3. Patients may NOT be asked to sign an ABN and subsequently be required to pay for these drugs.

4. Patients may NOT purchase these drugs and bring them to the facility for use.

Dropless cataract surgery is not new; we heard about this concept many years ago. While it is attractive to surgeons and patients, the question of separate reimbursement has been a sticking point. This CMS transmittal clarifies any questions regarding reimbursement.

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