When a Medicare cataract patient requests a premium intraocular lens instead of a standard IOL, Medicare lets you charge him the difference between what Medicare reimburses for use of a regular IOL ($150) and the actual lens cost. But billing patients for the difference, surgical centers must follow certain rules to stay in compliance with Medicare guidelines. Here's what you need to know.

$1,000 OUT OF POCKET Medicare allows you only a modest markup of $25 to $50 above the IOL cost for the handling of premium IOLs.

Here's how to correctly charge a Medicare patient for a premium IOL.
Premium lens cost	$1,100
Medicare reimbursement for regular IOL	- $150
	$950
Surgical facility's cost for handling of IOL	+ $50
Final suggested maximum amount you can charge patient	$1,000

Premium lens special rules
These premium lenses — CrystaLens, ReSTOR and ReZoom presbyopia-correcting lenses and the toric astigmatism-correcting IOL — are the only lenses for which Medicare lets ASCs charge patients the difference between what Medicare reimburses for use of a regular IOL ($150) and the actual lens cost. Medicare doesn't care what kind of IOL is placed in cataract procedures. If you implant a premium lens instead of a regular IOL, Medicare's reimbursement of $150 for the IOL is included in the payment of the cataract extraction procedure CPT codes (66984, 66982, etc.), as usual. Even though the physician used a different type of IOL, Medicare won't reimburse your center more for the use of a premium lens in the case. That is where billing the patient for the difference comes in — and the related compliance issues.

The ASC must supply and purchase the IOL. The surgeon can't purchase the premium lenses for Medicare cataract cases and bring them into the surgical facility for use in the cases. This is a compliance issue on a couple of fronts. First, Medicare doesn't let the facility bill for cataract extraction CPT codes with the —52 Reduced Services Modifier. Second, there's no other billing method to convey to Medicare that the facility didn't purchase the IOL for the case and therefore shouldn't be reimbursed for the IOL. Because there's no provision to let the facility break out the IOL implant portion of the procedure from the cataract extraction CPT code, Medicare requires you to supply and purchase the IOLs for all Medicare cataract cases. No exceptions. Medicare considers it to be a false claim if you submit a claim for a cataract extraction case for which you're receiving payment for the IOL when you didn't purchase the IOL.

You can't reimburse your surgeon for the IOL. Medicare doesn't let the facility reimburse the physician for any IOLs the physician purchased. It bears repeating: Medicare requires ASCs to purchase and supply the IOLs for all Medicare cataract cases.

What can you bill the patient? What can you charge patients for the use of premium IOLs in Medicare cataract cases? Medicare directs what you can charge patients for the premium lenses. Keep in mind that you're receiving the $150 as payment for the IOL from Medicare as part of the cataract CPT code. You must subtract that amount from the amount you charge the patient for the premium lens. Medicare allows you only a modest markup of $25 to $50 above the IOL cost for handling on premium IOLs. We break down the math on the preceding page.

Setting patients straight
If you want to indicate on your Medicare claim form that you used a premium IOL in the cataract procedure, bill the premium lenses using code V2787 for a toric astigmatism-correcting lens or code V2788 for presbyopia-correcting IOLs (CrystaLens, ReSTOR and ReZoom) with the —GY Non-Covered Modifier and/or the —GA Modifier appended to the V-code to indicate the patient has signed an Advanced Beneficiary Notice (ABN form or waiver). Because Medicare never covers the premium IOLs, you don't have to have Medicare patients sign an ABN. Still, it's a good idea to have them do so. This way, there'll be no misunderstandings with patients on what they'll owe you for these lenses.

It's also a good idea to check out your internal policy on the use of premium lenses in your cataract cases and make sure that you and your cataract surgeons won't get in trouble on this issue with Medicare.