Weekly eJournal From CorroHealth, April 26, 2023

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CODINGFORCATARACTSURGERY WITH INTROCULARLENSES

Quest ion:

The ophthalmologist performing cataract surgery at our OPPSfacility uses special vision-correcting intraocular lenses (IOLs) and performs a Refractive analysis during the surgery to guide the adjustment of the new vision-correcting lens. Neither the vision-correcting lens nor the refraction are covered by insurance. We have rolled the charges for both the refraction and the vision-correcting lens into the operating room revenue code 360 so the insurance can? t identify these specifically to deny them.

Is it appropriate to break these charges out and bill the patients separately, or should these special lens charges roll up into the surgical procedure charge to be billed to insurance?

Answ er:

The hospital should break out the non-covered charges on its claim. Furthermore, if the hospital reports a vision-correcting lens charge properly, Medicare and many insurers will cover a portion of the vision correcting lens charge The refraction, however, is non-covered by Medicare and most medical insurers. Here?s an image of a correctly prepared outpatient hospital claim for a vision-correcting lens and a refraction Note there are two charges for the IOL under revenue code 0276:

CODINGFORCATARACTSURGERY WITH INTROCULARLENSES

In this example, both lines under revenue code 0276 represent just one lens. The total charge for a vision correcting IOL is $1,516.90. The hospital broke that charge into two components -the conventional IOL charge at $466 90, and the vision-correcting function at $1,050 00, for a total charge of $1,516 90 The covered and non-covered portions are reported separately Medicare covers a conventional IOL when it is medically necessary to restore the patients vision due to cataracts. However, Medicare does not cover the function of an IOL that corrects for presbyopia or astigmatism Here?s an excerpt from an MLN from page five February 2023 on ?Medicare Vision Services?:

https://www cms gov/outreach-and-education/medicare-learning-networkmln/ mlnproducts/downloads/visionservices factsheet icn907165 pdf

?Cataract Removal & IOLs Billing Table 2 lists approved cataract removal and IOL insertion CPT and HCPCScodes. You must report the appropriate P-Cor A-CIOLs code even though we don? t cover that service part ?Note that last word in the excerpt: ?part ?The MLN isn? t particularly clear, but Medicare will cover a portion of the vision correcting IOL that serves the same clinical rose of a conventional IOL without the vision correcting properties. The vision-correcting function of an IOL may be offered at the patient?s option and at patient cost ?but the patient should not have to pay the full cost of the vision-correcting IOL, because the basic conventional implant is covered by Medicare. If the patient opts to have the surgeon implant a vision-correcting IOL, the patient must pay for the incremental cost of the vision-correcting feature ? but the cost of the basic IOL is covered and should be billed to insurance.

For the conventional IOL charge, most hospitals report V2632 for a posterior chamber intraocular lens: V2632 POSTERIORCHAMBERINTRAOCULARLENSIf the lens has vision-correcting properties, report V2787 or V2788 with the incremental additional charge for the vision-correcting function. Append modifier GYto the non-covered charge:

V2787 ASTIGMATISM CORRECTING FUNCTION OF INTRAOCULARLENS

V2788 PRESBYOPIA CORRECTING FUNCTION OF INTRAOCULARLENS

GY- Item or service statutorily excluded or does not meet the definition of any Medicare benefit.

CODINGFORCATARACTSURGERY WITH INTROCULARLENSES

Since V2787 and V2788 are statutorily non-covered, Medicare will adjudicate the charge for those HCPCSto patient liability The hospital should append a modifier GYto V2787 or V2788 to ensure that portion of the lens charge drops to patient liability Medicare adjudicated the example claim shown above as follows ? note the ?Non-Covered?column, which will drop to patient liability:

Many hospitals bill vision correcting IOLs incorrectly. Some hospitals bill the entire charge for a vision correcting IOLs on one line with V2787 or V2788, and the entire charge is assigned to patient liability.

That practice is non-compliant ? and unfairly shifts a greater portion of the charge to the patient. OPPShospitals should always report the conventional IOL when billing for cataract surgery with a vision correcting lens

When Medicare undertakes rate-setting for total APCreimbursement, a portion of the reimbursement is attributed to the cost of the covered implant By failing to report the conventional lens cost, Medicare?s OPPSrate-setting data from claims will have less cost attributed to the covered IOL

In 2023, Medicare OPPSfiles indicate that only 67.5%of all claims for CPT® 66984 also reported the conventional lens charge V2632 on the same claim Since not all claims for 66984 reported a covered lens charge, we might surmise that the APCrate understated the implant cost by as much as 32.5%. Here?s an excerpt from the 2023 OPPSAddendum P showing the portion of the total APCpayment that is attributed, through rate-setting analysis, to the IOL:

CODINGFORCATARACTSURGERY WITH INTROCULARLENSES

If all hospitals had reported the conventional IOL as appropriate, the total APC reimbursement might have been higher The cost of a non-covered vision-correcting lens is not included in the APCrate-setting process.

Incidentally, some hospitals confuse a vision-correcting IOL with a ?New Technology IOL? (NTIOL) ? these are two different things. HCPCSC1780 ? LENS, INTRAOCULAR(NEW TECHNOLOGY) is covered, but it is inaccurate There are no Medicare-approved NTIOLs Here?s the CMSwebsite that makes this clear, and also provides a download of the approved vision-correcting IOLs:

https://www cms gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/NTIOLs

Finally, most hospitals have a policy that the incremental cost of a vision-correcting lens must be paid by the patient/guarantor in full prior to the eye surgery.

Two new tools have recently been added to the Advisor tab in the PDE. Crosswalks to the appropriate HCPCS codes for radiologic contrast materials and radiopharmaceuticals and their corresponding CPT codes are now available

The crosswalks also provide information about the types of studies for which each drug is used, the associated NDCs, suggested revenue codes, CCI edits, MUEs, and more

In most cases, submitting charges for contrast and radiopharmaceuticals will not result in additional Medicare reimbursement for an OPPSfacility (Critical Access Hospitals are paid on a cost-reimbursement basis by Medicare.) However, it is still important to report the charge for the contrast agent or radiopharmaceutical for two reasons:

- Medicare bases APCreimbursement on cost data collected from hospital claims, and

- Some payers (like Medicaid) will reimburse contrast separately

Clients can access these tools via the Advisor Tab in the PDE:

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to thebest of CorroHealth'sknowledgeisaccurateat the timeof distribution. However, due to theever-changing legal/regulatorylandscape, thisinformation issubject to modification asstatutes, laws, regulations, and/or other updatesbecomeavailable. Nothingherein constitutes, isintended to constitute, or should berelied on as legal advice. CorroHealth expresslydisclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anythingcontained in thematerials, which areprovided on an "as-is"basisand should be independentlyverified beforebeingapplied You expresslyaccept and agreeto thisabsoluteand unqualified disclaimer of liability. Theinformation in thisdocument isconfidential and proprietaryto CorroHealth and is intended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduce or transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording, and broadcasting, or byanyinformation storageand retrieval system must beobtained in writingfrom CorroHealth. Request for permission should bedirected to Info@Corrohealth com.

According to an MLN Fact Sheet published in December, 2022, Medicare will require all 340(B) entities, including Critical Access Hospitals, which submit claims for separately payable Part B drugs and biologicals to report modifier ?JG?or ?TB?on claim lines for drugs acquired through the 340(B) discount program.

The MLN is available at the following website:

www cms gov/files/document/mln4800856-medicare-part-b-inflation-rebate-guidance-use340b-modifier pdf

ALL FACILITIESREQUIRED TO REPORT340B MODIFIERSIN 2024

This is a substantial change from the original 340B billing requirement Previously, Critical Access Hospitals and Maryland All-Payer or Total Cost of Care Model hospitals were not required to report a modifier on 340(B) drugs. CMSissued a companion ?FAQ?document which reiterates this point:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ Downloads/Billing-340B-Modifiers-under-Hospital-OPPS.pdf

ALL FACILITIESREQUIRED TO REPORT340B MODIFIERSIN 2024

The FAQ document provides a table summarizing the requirement for affected provider types:

The modifier requirement does not apply to all drugs purchased under 340(B), although hospitals may opt to report the modifier for all 340B drugs. The obligation to append a modifier applies to only Part B drugs and biologicals assigned OPPSStatus Indicator G or K(?separately payable?under OPPS.)

PARA Dat a Edit or users may identify the line items within the hospital charge master which are separately payable drugs by navigating to the ?Filters?tab, clicking the checkbox next to ?Status Indicator?, and clicking on both status G and status K, as illustrated below:

PARA invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS). It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources. Click each link for t he PDF!

Thursday, April 20, 2023

New s

- Billing Medicare Part B for Insulin with New Limits on Patient Monthly

Coinsurance

- Medical Review & Compliance: Respond to Additional Documentation

Requests

- Hospice: Comparative Billing Report in April

Com pliance

- Home Health Rural Add-On Policy

Claim s, Pricers, & Codes

- Grandfathered Tribal Federally Qualified Health Centers: CY2023 Rate

Event s

-

Medicare Ground Ambulance Data Collection System: Office Hours Session ? April 27

-

Medicare Shared Savings Program: Navigating the Application Webinar ?

May 8

-

Clinical Laboratory Fee Schedule: Present or Speak at Upcoming Meetings

r ans mit t al s

Therew ereTWENTY-TWOnew or revised Transmittalsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

TRANSMITTAL R11942CP

TRANSMITTAL R11995BP

TRANSMITTAL R11962PI

TRANSMITTAL R11988CP

TRANSMITTAL R11990OTN

TRANSMITTAL R11966CP

TRANSMITTAL R11989OTN

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TRANSMITTAL R11977OTN

TRANSMITTAL R11976OTN

2 m edl ear ns

Therew ereTWOnew or revised MedLearnsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to the best of ParaRev?s knowledgeisaccurate at thetime of distribution. However, dueto theever changing legal/regulatorylandscapethisinformation issubject to modification, asstatutes/laws/regulationsor other updatesbecomeavailable.

Nothingherein constitutes, isintended to constitute, or should berelied on as, legal advice ParaRev expressly disclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anythingcontained in thematerials, which areprovided on an ?as-is?basisand should beindependentlyverified beforebeing applied.

You expresslyaccept and agree to thisabsoluteand unqualified disclaimer of liability.Theinformation in this document isconfidential and proprietaryto ParaRev and isintended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduce or transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording and broadcasting, or byanyinformation storageand retrieval system must be obtained in writingfrom ParaRev. Request for permission should be directed to sales@pararevenue.com.

ParaRev is excited to announce we have joined industry leader CorroHealt h to enhance the reach of our offerings! ParaRev services lines are additive in nature strengthening CorroHealt h?s impact to clients?revenue cycle. In addition, you now have access to a robust set of mid-cycle tools and solutions from CorroHealt h that complement ParaRev offerings

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As always, we are available to answer any questions you may have regarding this news We thank you for your continued partnership