Notification



Notification Issue Date:



Claim Payment Policy


Title:Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens

Policy #:11.05.10b

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Conventional intraocular lenses (IOLs) (V2630-V2632) inserted following removal of a cataract are covered and eligible for reimbursement by the Company.

If a member chooses to have a presbyopia-correcting IOL (V2788) or an astigmatism-correcting IOL (V2787) inserted following cataract removal, the correcting function of the lens itself is not covered, as it is considered a benefit contract exclusion. In those cases, the surgical procedure for the insertion is covered and eligible for reimbursement; however, the member is financially responsible for the portion of the charge for the presbyopia- or astigmatism-correcting IOL that exceeds the charge for the conventional IOL.

When a member requests insertion of a presbyopia- or astigmatism-correcting IOL instead of a conventional IOL following cataract removal, the individual should be informed (by the facility and physician) that services that are specific to the insertion or adjustment of the presbyopia- or astigmatism-correcting IOL and subsequent treatments related to the presbyopia- or astigmatism-correcting functionality of the IOL are not covered or eligible for reimbursement.

Providers must document on the Company-approved form that any individual who consents to the presbyopia- or astigmatism-correcting IOL has been informed that this device is not covered and has agreed to pay the portion of the charge for the presbyopia- or astigmatism-correcting IOL that exceeds the charge for the conventional IOL.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, a presbyopia- or astigmatism-correcting intraocular lens (IOL) is a benefit contract exclusion for all of the Company’s products.

FINANCIAL RESPONSIBILITY

For individuals receiving a presbyopia- or astigmatism-correcting IOL, the member is not responsible for the cost of the conventional IOL or the surgical procedure for insertion of the lens. However, the member is financially responsible for the portion of the charge for the presbyopia- or astigmatism-correcting IOL that exceeds the charge for a conventional IOL.

BILLING GUIDELINES

Providers should report the appropriate Healthcare Common Procedural Coding System (HCPCS) code for the insertion of the conventional IOL: V2630, V2631, or V2632.

For individuals who are receiving the presbyopia-correcting IOL, providers should report the appropriate add-on code (V2788). For individuals who are receiving the astigmatism-correcting IOL, providers should report V2787.

Description

Generally, when an individual has a cataract removed, a conventional intraocular lens (IOL) is used to replace the eye's natural crystalline lens. The IOL is a small, lightweight clear disk.

Presbyopia is a type of refractive error that results in progressive loss of the focusing power of the lens of the eye. As the natural lens becomes thicker and less flexible with age, individuals with presbyopia may experience difficulty seeing objects at a distance, up close, or both.

Astigmatism is an optical defect in which refractive power is not uniform in all directions. Light rays entering the eye are bent unequally by different meridians, preventing formation of a sharp image focus on the retina.

A presbyopia- or astigmatism-correcting IOL is an optional replacement for the natural lens of the eye.

In most cases, presbyopia- and/or astigmatism-correcting IOLs eliminate the need for eyeglasses or contact lenses. A single presbyopia- or astigmatism-correcting IOL can provide what would otherwise be achieved with both a conventional implantable IOL and corrective eyeglasses or contact lenses.
References


Company Benefit Contracts.

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. CMS Manual System. Pub 100-04: Medicare Claims Processing. Transmittal 1228. Instructions for implementation of CMS 1536-R; Astigmatism-correcting intraocular lens (A-C IOLs). [CMS Web site]. 04/27/2007. Available at: http://www.cms.hhs.gov/Transmittals/Downloads/R1228CP.pdf. Accessed May 11, 2018.

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. CMS Rulings. Ruling No. 05-01. [CMS Web site]. 05/03/05. Available at: http://www.cms.hhs.gov/Rulings/downloads/CMSR0501.pdf. Accessed May 11, 2018.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

H52.201 Unspecified astigmatism, right eye

H52.202 Unspecified astigmatism, left eye

H52.203 Unspecified astigmatism, bilateral

H52.209 Unspecified astigmatism, unspecified eye

H52.211 Irregular astigmatism, right eye

H52.212 Irregular astigmatism, left eye

H52.213 Irregular astigmatism, bilateral

H52.219 Irregular astigmatism, unspecified eye

H52.221 Regular astigmatism, right eye

H52.222 Regular astigmatism, left eye

H52.223 Regular astigmatism, bilateral

H52.229 Regular astigmatism, unspecified eye

H52.4 Presbyopia



HCPCS Level II Code Number(s)



S0596 Phakic intraocular lens for correction of refractive error

V2630 Anterior chamber intraocular lens

V2631 Iris-supported intraocular lens

V2632 Posterior chamber intraocular lens

V2787 Astigmatism-correcting function of intraocular lens

V2788 Presbyopia-correcting function of intraocular lens


Revenue Code Number(s)

0276 Medical/Surgical Supplies and Devices - Intraocular Lens

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.15.10b
06/20/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens.


Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 04/01/2012
Version Issued Date: 04/01/2012
Version Reissued Date: 06/20/2018

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