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Medicare Reimbursement for Presbyopia-Correcting and Toric IOLs

Topic: Presbyopia IOLs

Sponsor: Corcoran Consulting Group

Updated: 02/02/2022

Corcoran Consulting Group

Most intraocular lenses (IOLs) contain only spherical power and do not correct for presbyopia. Some IOLs contain sphere powers for both distance and near, and are known as presbyopia-correcting IOLs (P-C IOLs). Other IOLs also contain cylinder power for correction of astigmatism; they are known as toric IOLs or astigmatism-correcting IOLs (A-C IOLs). Some IOLs correct both presbyopia and astigmatism.

This monograph examines how these IOLs fit within longstanding Medicare coverage and payment rules for refractive cataract surgery. We address the IOL feature and related professional services that are noncovered as described in the ground-breaking May 3, 2005 CMS ruling, the associated August 5, 2005 Transmittal,2 and MedLearn Matters’ MM39273 concerning presbyopia-correcting IOLs. We also address the IOL feature and related professional services that are noncovered based on the pertinent January 22, 2007 ruling (CMS-1536-R)4 concerning astigmatism-correcting IOLs.

This monograph also identifies the applicable CPT and HCPCS codes, as well as diagnosis codes, that pertain to the professional and facility services related to cataract surgery and the implantation of P-C and A-C IOLs. Relevant modifiers are noted as well.

In the Appendix, there are several model forms for your use. These forms may be used as notification for patients and third party payers, as well as to document the boundary between insurance payments and patient financial responsibility. Several sample letters are included to communicate with third party payers about refractive cataract surgery including implantation of P-C and A-C IOLs.