Co Management Made Easier

Making the Most of Premium IOLs:
Your guide to medical coding
and compliance.
John Rumpakis, OD, MBA

3
Making the most of premium IOLs
What Are You Waiting For?
The excitement surrounding the premium IOLs is growing
within the ophthalmological and optometric professions,
yet there remains great confusion about many aspects of
the procedure and process. Why all of the excitement?
After all, isn’t this just another surgical procedure and if
so, why should optometry be involved, much less excited?
Isn’t this exclusively the territory of ophthalmology? While
the surgical procedure itself is confined to ophthalmology,
the primary driver of the patient selection and market is
optometry – more specifically you!
Just as in the refractive surgery market – optometry has
a significant opportunity waiting to be developed. Co-
managing a cataract patient today is much more involved
and rewarding process than it has been in years. With the
advent of the Premium Intraocular Lens category (both
for presbyopia in 2005 and astigmatism in 2007), patient
choices are much broader and the ability to provide
excellent surgical corrective solutions abound.
Let’s revisit a little history. On May 3, 2005, Medicare set
forth policy concerning the requirements for determining
payment for insertion of presbyopia correcting intraocular
lenses (PCIOLs) following cataract surgery (http://www.
cms.hhs.gov/Rulings/downloads/CMSR0501.pdf). This
ruling from the Centers for Medicare & Medicaid Services,
which allows surgeons to bill the patient for the extra
costs involved in implanting these lenses was certainly
unprecedented, revolutionary, and unexpected in the
ophthalmic area. This CMS policy created a new market
within optometry and ophthalmology, specifically for
patients aged 50 years and older. This specific market
demographic was and continues to experience tremendous
growth. The 50+ market is expected to grow seven times
faster than any other segment during the next 15 years
while the volume of refractive surgical candidates have
decreased or are flat because baby boomers have reached
their 50’s. Although 50-something’s may not make good
refractive surgery candidates they certainly are candidates
for a presbyopia correcting IOL following cataract surgery.
Subsequent to this, on January 22, 2007, Medicare set
forth policy concerning the requirements for determining
payment for insertion of astigmatism-correcting
intraocular lenses (ACIOLs) following cataract surgery
(http://www.cms.hhs.gov/Rulings/downloads/CMS1536R.
pdf).
These recent Medicare rulings concerning presbyopic
and astigmatic correcting IOLs are a huge win for
cataract surgery patients and physicians alike. Before this
ruling, Medicare patients who needed cataract surgery
were denied access to technology such as an approved
multifocal IOL like AcrySof® ReSTOR® IQ IOL or the AcrySof®
IQ Toric lenses for astigmatism. Furthermore, any extra
tests and work specifically related to the correction of
either presbyopia or astigmatism are not covered and
need to be charged directly to the patient as an out-of-
pocket fee. This also represented a change in policy and
procedure. Rather than send a claim directly to Medicare
for payment, both optometrists and ophthalmologists must
bill patients directly for these services and the non-covered
component of the IOL itself, which in and of itself requires
even greater communication and coordination between
these two groups to achieve the best outcomes that this
technology can deliver. These CMS rulings essentially
removed the balance-billing obstacle by establishing that
all charges, either by physician or facility, for additional
items and services intended to correct presbyopia or
astigmatism are non-covered services. Consequently,
collecting for non-covered services from the patient
doesn’t constitute balance billing and effectively removes
the intrinsic obstacles contained within the process.
As a result, Medicare beneficiaries may upgrade from a
conventional monofocal IOL to either a PCIOL or ACIOL,
as long as they request the additional products/services
and are willing to pay all charges beyond those associated
with standard cataract surgery. To the extent that Medicare
patients are willing to pay the extra costs for a PCIOL or
ACIOL, facilities and physicians may receive an additional
payment from the patient than that amount allowed by
Medicare for insertion of a conventional IOL following
cataract removal. Prior to the May 2005 ruling, Medicare
officials understood that the new IOL technology was
a technology that patients were interested in receiving
and the rules in place at that time were an obstacle to
good patient care. As long as providers and patients have
an honest discussion about the pros and cons of the
lenses and the cost and coverage differences between
conventional and these premium IOLs, it creates a win-win
situation for all concerned. This decision represented an
important new beginning for Medicare policy, moving us in
the direction of technological advance, individual choice,
and patient supremacy over bureaucracy.
New Market/New Procedures/New Thought
Process
To understand how physicians and practices can most
appropriately incorporate this new technology into their
patient offerings, a fundamental understanding of the
current process is critical– because this will not be done
without scrutiny of the federal government’s oversight

4
office – the Office Of Inspector General (OIG). M.D.’s
and O.D.’s alike who are going to be providing the pre-,
intra-, and post-surgical care must have the knowledge
to understand the differences between conventional IOL
implantation and PCIOL implantation so that they can
avoid the pitfalls from inappropriate billing policies and
maximize the benefit of incorporating refractive IOLs into
their practice.
Doing It Right –
Traditional Monofocal Implantation
Visual Tests Prior to Cataract Surgery
In most cases, a comprehensive eye examination (ocular
history and ocular examination) and a single scan to
determine the appropriate pseudophakic power of the
intraocular lens are sufficient. In most cases involving a
simple cataract, a diagnostic ultrasound A-scan is used
(See example below). For patients with a dense cataract,
an ultrasound B-scan may be used. Accordingly, where
the only diagnosis is cataract(s), Medicare does not
routinely cover testing other than one comprehensive eye
examination (or a combination of a brief/intermediate
examination not to exceed the charge of a comprehensive
examination) and an A-scan or, if medically justified,
a B-scan. Claims for additional tests are denied as not
reasonable and necessary unless there is an additional
diagnosis and the medical necessity for the additional tests
is fully documented.
Transfer of Care Between Providers
Ordinarily, the global surgery fee schedule allowance
includes preoperative evaluation and management services
rendered the day of or the day before surgery, the surgical
procedure, and the post-operative care services within the
defined post-operative period. Post-operative care may be
rendered by an ophthalmologist, optometrist, or providers
who are licensed to render such services. When a physician
transfers the care of a patient to another provider outside
their group practice within the global period, it is consid-
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Procedures, services, supplies
(explain unusual circumstances)
CPT-HCPCS - Modifier
Diagnosis
code
Charges Days or
units
1 2/25/2010 11 92004 1 XXX.XX 1
2 2/25/2010 11 92015 2 XXX.XX 1
3 2/26/2010 11 76519-26-50 1 XXX.XX 2
Diagnosis: 366.16, Nuclear Sclerosis (O.D. or M.D.)
ered “a transfer of care”. A transfer of care occurs when
the referring physician transfers the responsibility for the
patient’s complete care to the receiving physician at the
time of referral, and the receiving physician documents
approval of care in advance. Each provider must agree and
document the transfer of care in the medical record. The
agreement must be in the form of a letter or written as a
notation in the discharge summary/hospital records or Am-
bulatory Surgical Center records. The appropriate CPT®-4
modifiers must be added to the surgical procedure code:
• -54 Surgical care only
• -55 Post-operative management only
• -79 Unrelated Procedure or Service by the Same Physician
During the Post-operative Period
The claim for the surgical care only and the claim for the
post-operative care only must identify the same surgical
date of service and the same surgical procedure code.
Modifier 54 must be reported with the surgical care only.
For claims where physicians share post-operative care, the
assumed and/or relinquished dates of care must be indi-
cated in Item 19 of the CMS-1500 claim form, or electronic
media claim equivalent. Where a transfer of post-operative
care occurs, the receiving physician cannot bill for any
part of the global services until he/she has provided at
least one service. Once the physician has seen the patient,
that physician may bill for the service. When more than
one physician bills for the post-operative care, the post-
operative percentage is apportioned based on the number
of days each physician was responsible for the patient’s
care. The maximum percentage for post-operative care
for 66984 is 20 percent, and the length of the associ-
ated global period is 90 days. Generally, the diagnosis for
cataract is the most appropriate (366.XX) to use, but many
carriers will also accept pseudophakia (V43.1) code for the
post-operative portion of care.

5
Billing It Right – Traditional Monofocal Implantation
Example: Billing for 1st Eye
Dr. Jones performs procedure code 66984 on March 1st and cares for the patient through March 2nd. Dr. Smith assumes
responsibility for the patient on March 3rd for the remainder of the global period.
Dr. Jones’ claim contains the following:
03/01/2010 66984 54
03/01/2010 66984 55 assumed 03022010 relinquished 03022010
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
1 3/1/2010 11 66984-54-RT 1 XXX.XX 1
2 3/1/2010 11 66984-55 RT 1 XXX.XX 1
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
1 3/1/2010 11 66984-55-RT 1 XXX.XX 1
Surgeon
billing
CPT code
used
ICD-9 code
used
Typical
charges
Coverage
Line 1
Line 2
66984-54-(RT/LT)
66984-55-(RT/LT)
366.16
Nuclear Cataract
$800.00* Send to carrier as
traditionally billed
Optometrist
billing
CPT code
used
ICD-9 code
used
Typical
charges
Coverage
Line 1 66984-55-(RT/LT) 366.16 (Nuclear
Cataract) or V43.1
(Pseudophakia)
Maximum of 20% of surgeon’s
fee. Based upon portion of
global post-operative care
provided.
Send to carrier as
Diagnosis: 366.16, Nuclear Sclerosis (Surgeon’s Billing)
Diagnosis: 366.16, Nuclear Sclerosis (O.D. Post-Operative Portions)
Format of typical charges surrounding the patient with cataracts with conventional
IOL implantation & Co-management
Dr. Smith’s claim contains the following:
Traditional Billing Process For Monofocal IOL Implantation & Co-Management

6
Current Coding Guidelines For IOL Implantation &
Co-Management For A Patient Who Is Upgrading
To A Premium IOL
Authors Note - The following claim form examples are for
a Presbyopic-Correcting IOL (PCIOL), however the same
protocol would follow for an Astigmatic correcting IOL
(ACIOL) by substituting V2787 – Astigmatism Correcting
Function of Intraocular Lens in place of V2788 - Presbyopia
Correcting Function of Intraocular lens. Additionally, the
diagnosis of Astigmatism 367.2X (5th digit dependent on
specific type of Astigmatism) would be used in place of the
diagnosis of Presbyopia 367.4
Picking The Right Surgical Code
The code for standard cataract surgery fees is CPT code
66984, and it is recommended that physician’s offices use
this code when billing Medicare or commercial insurance
when a patient elects a PCIOL. CPT code 66984 is for the
covered portion of the surgery and IOL. That part of the
process should be billed in standard fashion. For the non-
covered upgrade, code V2788 should be used to describe
the upgrade to a PCIOL. It is also advised that surgeons
should not use CPT 66982 (complex cataract) when
implanting presbyopia-correcting IOLs, unless the require-
ments of code 66982, as defined in the CPT, are also met
or physicians receive specific instructions from CMS that
state that this is acceptable.
Since the OIG will be watching for patterns of abuse with
the advent of this new policy, surgeons and O.D.’s alike
should be careful not to change patterns of recommend-
ing cataract surgery to their patients. Moreover, surgeons
may not require patients to elect a PCIOL as a condition of
implanting an IOL; the patient must always have the op-
tion of selecting a conventional monofocal IOL.
Charging The Patient
The beneficiary is responsible for paying for the portion
of the physician’s charge for the PCIOL that exceeds the
physician’s charge for a conventional IOL. There are many
non-covered technical work expenses associated with the
preoperative process of presbyopic cataract surgery and
many additional non-covered work expenditures associat-
ed with the post-operative care, which is necessary in order
for patients to achieve satisfactory near, intermediate, and
distance vision.
While most anticipate that residual refractive error will be
corrected with additional surgery, keep in mind that the
existing covered Medicare benefit of one pair of spectacle
lenses, an ophthalmic frame, or one pair of contact lenses
per surgery remains intact even for the patient who re-
quested the upgrade to a PCIOL procedure/product.
Using An Advance Beneficiary Notice (ABN) or
Notice Of Exclusion From Medicare Benefits
(NEMB)
Since these additional tests are not covered by a carrier,
and the patient will most likely be bearing 100% of the ad-
ditional non-covered cost, there are strict rules of notifica-
tion that must be followed before performing and billing
the tests. Practices should have a patient sign a waiver
and keep it with his chart. It is critical that all the specifics
of the elective part of the procedure need to be detailed
in this waiver to be given to and signed by the patient.
The waiver should clearly define what Medicare pays for
and for what the patient is financially responsible. The
most appropriate document for this purpose is NOT the
Advance Beneficiary Notice as is commonly used in day-to-
day practice, but is the CMS document called the Notice
of Exclusions From Medicare Benefits (NEMB) form http://
www.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf .
While this form is not required, it’s use is “strongly encour-
aged” by CMS. This form is not to be sent to Medicare; its
purpose is for documentation only and should remain in
the patient’s file.
Visual Tests Prior to Cataract Surgery
Just as in conventional or traditional monofocal implanta-
tion surgery, a comprehensive eye examination (ocular
history and ocular examination) and a single scan to
determine the appropriate pseudophakic power of the in-
traocular lens will be covered by Medicare where the only
diagnosis is cataract(s).

7
However, when the patient requests an upgrade to a
PCIOL, there are additional tests, both pre- and post- op-
eratively, that, if medically necessary, may be billed directly
to the patient as they are deemed non-covered services.
The typical set of additional tests performed, in addition to
the comprehensive examination and A-scan could include:
• Initial Consult (separate from Comprehensive Exam)
• Dry eye evaluation and treatment
• Corneal topography
• Wavefront aberration testing
• Pachymetry
• Additional A-scan & Lenstar or IOLMaster
• Contact lens trial ﬁtting
• Additional refractions, post-operative evaluations and
progress evaluations to deal with residual refractive error
• Refractive surgical procedures for the purpose of reduc-
ing dependence on eyeglasses or contact lenses (e.g.,
limbal relaxing incisions, corneal relaxing incisions, LASIK,
etc.).
These additional tests and care protocols may be itemized
to the patient or globally grouped into a PCIOL package
of services which is directly billed to the patient. Keep in
mind, however, that the surgeon, the O.D., and most im-
portantly, the patient must have a clear understanding of
the additional services performed, who’s performing them,
and what the associated cost will be prior to them being
provided.
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
1 2/25/2010 11 92004 1 XXX.XX 1
2 2/25/2010 11 92015 2 XXX.XX 1
3 2/26/2010 11 76519-26-50 1 XXX.XX 2
Diagnosis: 366.16, Nuclear Sclerosis (O.D. or M.D.)
Transfer of Care Between Providers
Just as with traditional monofocal implantation surgery,
the global surgery fee schedule allowance includes preop-
erative evaluation and management services rendered the
day of or the day before surgery, the surgical procedure,
and the post-operative care services within the deﬁned
post-operative period. Post-operative care may be rendered
by an ophthalmologist, optometrist, or providers who are
licensed to render such services and all of the same guide-
lines remain as explained earlier

8
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
1 3/1/2010 11 66984-54-RT 1 XXX.XX 1
2 3/1/2010 11 66984-55-RT 1 XXX.XX 1
Diagnosis: 366.16, Nuclear Sclerosis (Surgeon’s Billing)
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
1 3/1/2010 11 V2788 (Presbyopic Cataract
Surgery)
1 XXX.XX 1
Diagnosis: 367.4, Presbyopia (O.D.s billing to patient with NEMB)
Billing It Right – Presbyopic IOL Implantation
Example: Billing for 1st Eye
Dr. Jones performs procedure code 66984 on March 1st and cares for the patient through March 2nd. Dr. Smith assumes
responsibility for the patient on March 3rd for the remainder of the global period.
03/01/2010 66984 54
In addition the surgeon would bill to the patient the additional fee for the non-covered component of implan-
tation of the PCIOL with the ICD-9 diagnosis of Presbyopia 367.4.
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
Surgery)
1 XXX.XX 1
Diagnosis: 367.4, Presbyopia (Surgeon’s billing to patient with NEMB)
Dr. Smith’s claim contains the following: 03/01/2010 66984 55 assumed 03032010 relinquished 05302010
In addition to the standard post-operative care the O.D. would also bill their portion of the additional post-
operative services provided due to the implantation of a PCIOL with the ICD-9 diagnosis of Presbyopia 367.4.
It is important to note that each physician participating in the care of the patient should independently have
the patient sign a Medicare form NEMB (Notice of Exclusion from Medicare Beneﬁts) for their independent
services provided.
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
1 3/1/2010 11 66984-55-LT 1 XXX.XX 1
Diagnosis: 366.16, Nuclear Sclerosis (O.D.’s post-operative billing )

9
Billing for 2nd Eye
Dr. Jones performs procedure code 66984 on the 2nd eye on May 1st and cares for the patient through May 2nd. Dr.
Smith assumes responsibility for the patient on May 3rd for the remainder of the global period.
05/01/2010 66984 79 54
05/01/2010 66984 79 55 assumed 05022010 relinquished 05022010
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
1 5/1/2010 11 66984-79-54-LT 1 XXX.XX 1
2 5/1/2010 11 66984-79-55-LT 1 XXX.XX 1
Diagnosis: 366.16, Nuclear Sclerosis (Surgeon’s billing - second eye)
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
1 5/1/2010 11 66984-79-55-LT 1 XXX.XX 1
Diagnosis: 366.16, Nuclear Sclerosis (O.D.’s post-operative billing - second eye)
Just as in billing for the ﬁrst eye, the surgeon would bill to the patient the additional fee for the implantation
of the PCIOL with the ICD-9 diagnosis of Presbyopia 367.4.
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
Surgery)
1 XXX.XX 1
Diagnosis: 367.4, Presbyopia (Surgeon’s billing to patient with NEMB - second eye)
Dr. Smith’s claim contains the following:
05/01/2010 66984 79 55 assumed 05032010 relinquished 07302010
Dates of
service
from
Dates of
service
to
Place of
service
Type of
service
Diagnosis
code
Charges Days or
units
Surgery)
1 XXX.XX 1
Diagnosis: 367.4, Presbyopia (O.D.’s billing to patient with NEMB - second eye)
Similarly, in addition to the standard post-operative care the O.D. would also bill their portion of the addition-
al post-operative services provided due to the implantation of a PCIOL with the ICD-9 diagnosis of Presbyopia
367.4.

10
As noted in our earlier example of traditional monofocal
implantation claims where physicians share post-operative
care, the assumed and/or relinquished dates of care must
be indicated in Item 19 of the CMS-1500 claim form, or
electronic media claim equivalent and the same rules exist
where a transfer of post-operative care occurs. Based on
the example above, reimbursement for the post-operative
care is apportioned as follows (excluding Dr. Jones’s surgi-
cal portion corresponding with modifier -54):
The maximum percentage for post-operative care for
66984 is 20 percent, and the length of the associated
global period is 90 days.
Fee schedule amount for 66984 = $800.00
(For Illustrative Purposes Only)
Post-operative days 90
Total Post-operative reimbursement if performing 100% of
post-operative care (20%) = $160.00
Dr. Jones provided care for the first day. To determine the
allowed amount, divide the 1 day by the total number of
post-operative days (90). This equals 1.11%. Multiply the
1.11% by the 20% post-operative care amount, thus reim-
bursement would equal $1.76.
(1 day divided by 90 days (total post-operative) = 1.11%;
1.11% x $160.00 (20% post-operative) = $1.76)
Dr. Smith provided care for the last 89 days. To determine
the allowed amount, divide the 89 days by the total num-
ber of post-operative days (90). This equals 98.89%. Mul-
tiply the 98.89% by the 20% post-operative care amount,
thus reimbursement would equal $158.22
(89 days divided by 90 days (total post-operative) =
98.89%; 98.89% x $160.00 (20% post-operative) = $158.22)
Surgeon
billing
CPT code
used
ICD-9 code
used
Typical
charges
Coverage
Line 1 66984-54-(RT/LT) 366.16
Nuclear Cataract
$800.00* Send to carrier as
Line 2 V2788 Presbyopia
Cataract Surgery
367.4
Presbyopia
$1000.00 Non-covered services above
traditional cataract - bill to
patient
Optometrist
billing
CPT code
used
ICD-9 code
used
Typical
charges
Coverage
Line 1 66984-55-(RT/LT) 366.16 Maximum of 20% of surgeon’s
fee. Based upon portion of global
post-operative care provided.
Send to carrier as traditionally
billed
Line 2 V2788 Presbyopia
Cataract Surgery
367.4
Presbyopia
$500.00 Non-covered services above
Format of typical charges surrounding the patient with cataracts upgrading to a presbyopia-correcting IOL
$1.76 (Dr. Jones)+ $158.22 (Dr. Smith) = $160.00 Total
post-operative care
But, recognize in this case that there is also significant, ad-
ditional revenue generated by both parties.
Conclusions
These rulings from CMS certainly sounded a clarion call
in policy shift for both patients and physicians. Patients
now have the option of having the best technology avail-
able to satisfy their visual needs for their lifestyles, and
ODs and MDs can provide it without the fear of losing
significant revenue. With O.D.’s providing the majority of
primary eye care visits in the country, it is vitally important
that they are knowledgeable about these technologies
and the opportunity that exists by educating their patient
base about them. Ophthalmology and optometry can and
must work together to bring this exciting new technology
to the mainstream. These ruling create a climate for a true
win-win-win for the O.D., the M.D., and most importantly
for the patient who is able to now have options in their
own health care decisions. With the “boomer generation”
having less than a year before hitting the Medicare system,
we have the tools at our disposal to satisfy their visual de-
mands, and preserve their active lifestyles. The government
has done its part to create policy that provides us flexibility
and options in being able to fulfill our patient demands
without financial compromise. Don’t be left out of being a
part of these exciting times in eye care – there is no com-
pelling reason to remain ignorant – take advantage of the
opportunity before you and make the most of it – for your
patient, your practice, and yourself.

11
Dr. Rumpakis is currently President & CEO of Practice Resource Management, Inc., a
firm that specializes in providing a full array of consulting, appraisal, and management
services for healthcare professionals and industry. He has developed some of the lead-
ing web-based software applications for the medical/eye care field such as Reimburse-
mentPLUS® (www.ReimbursementPlus.com), the industry leading internet-based CPT
Code Information and Reimbursement software program and WhatsMyPracticeWorth.
com® (www.WhatsMyPracticeWorth.com), an dynamic online practice appraisal tool.
He is also the founder of Opt-ED® Professional Continuing Education which creates
and delivers top tier continuing education around the country as well as Opt-IN® which
provides optometric marketing and promotional services.
Named the Chief Medical Coding Editor for Review of Optometry, he has been exten-
sively published on the topics of third party coding & billing, practice management,
team building, maximizing effectiveness and profitability, including the textbook “Busi-
ness Aspects of Optometry”. Dr. Rumpakis is a popular lecturer both nationally and
internationally. In addition to having had a successful solo practice, Dr. Rumpakis devel-
oped the practice management curriculum at Pacific University College of Optometry
and taught optometric & medical economics there for over a decade.
A 1984 graduate of Pacific University College of Optometry, he currently serves on the
AOA’s Congress Committee, was the primary architect of the AOA Advantage program,
and has served as chair for the Student Debt Special Project Team, the Gold Disk Proj-
ect Team, and the Practice Perpetuation Project Team.

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