Medicare Reimbursement for TECNIS Symfony® IOLS

Topic: IOL

Sponsor: Abbott Medical Optics

Updated: 01/26/2017

Abbott Medical Optics

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).

Two new IOLs, from Abbott, in the TECNIS Symfony® family, offer presbyopia-correction alone or in concert with astigmatism-correction. These IOLs may appeal to patients because they probably lessen how often people wear glasses following refractive cataract surgery.

This monograph examines how the Abbott TECNIS Symfony® IOLs fit within longstanding Medicare coverage and payment rules for refractive cataract surgery. We address the IOL feature and related professional services that are non-covered as described in the ground-breaking May 3, 2005 CMS ruling,1 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 non-covered 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.