Medicare Coverage of Optometry and Co-management Services
Medicare considers a doctor of optometry as a physician with respect to all services the optometrist is authorized to perform under state law or regulation. Optometrists are licensed by the state in which they practice, and their scope of optometric practice is determined by a state’s designated governing body for optometry, which varies from one state to another.
In addition to adhering to state law scope of practice requirements, services provided by optometrists must be medically reasonable and necessary for the diagnosis or treatment of illness or injury in order to be covered by Medicare, and must meet all applicable coverage requirements. While the state laws and regulations are the beginning point for determining services that can be provided by an optometrist, Medicare does specify:
- Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from Coverage” (PDF, 442 KB) for exclusions from coverage that apply to vision care services
- Medicare Claims Processing Manual (PDF, 1.5 MB) Chapter 12, “Physician/Practitioner Billing,” for information dealing with payment for items and services furnished by optometrists
Medicare established global surgical packages (PDF, 645 KB) in 1992 which include all the necessary services normally furnished by a surgeon before, during and after a procedure. In these instances, Medicare payment for a surgical procedure includes the preoperative, intraoperative and postoperative services routinely performed by the surgeon. There are three types of global surgical packages based on the number of post-operative days:
Global surgery is applicable in any setting, and the postoperative care is valued at a designated percentage of the overall global package. For example, cataract surgery has a 90-day global fee period with postoperative care for cataract surgery valued at 20 percent of the global surgery package.
When a patient requires ocular surgery, the operating ophthalmologist (surgeon) has the ultimate responsibility for the preoperative assessment, surgical procedure and postoperative care of the patient, beginning with the determination of the need for surgery and ending with completion of the postoperative care, contingent on medical stability of the patient. However, when medically appropriate, the operating ophthalmologist’s postoperative care responsibilities may be delegated to another qualified healthcare practitioner as part of a co-management arrangement or as a transfer of care, under appropriate circumstances.
Shared responsibility of postoperative care, co-management, following ocular surgery at times may be necessary or justifiable as the preferred course of action. Legitimate circumstances under which co-management may be considered include:
- Patient difficulty in arranging transportation to the surgeon-ophthalmologist’s office for follow-up care due to distance; or
- In cases in which the surgeon-ophthalmologist’s availability is an issue, or when there is a change in the postoperative course necessitating a different course of treatment
Delegation of the operating ophthalmologist’s responsibilities to a non-operating optometrist is only allowed:
- After obtaining the patient’s informed written consent
- A copy of this written agreement should be maintained by both the surgeon and the co-manager
- The patient must be sufficiently stable prior to transfer of care or co-management
- The non-operating practitioner must be willing and qualified to accept the care of the patient, as well as be practicing within applicable state law
There should be no routine arrangements between an operating ophthalmologist and non-operating practitioners to automatically share post-operative co-management service, even if the non-operating practitioner originally referred the patient to the operating ophthalmologist. Post-operative co-management or transfer of care should be determined based on the clinical stability and needs of each individual patient. Also, physicians and non-physician practitioners should be aware that quid pro quo arrangements between referring and accepting practitioners are prohibited. The Office of Inspector General for HHS has expressed concern regarding co-management services based on economic considerations rather than clinical appropriateness. The anti-kickback statute makes it a criminal offense to knowingly and willfully offer, pay, solicit or receive any remuneration to induce or reward referrals of items or services reimbursable by Medicare or any other federal health care program.
Billing for Ocular Surgery and Co-management Services
In addition to the surgery, Medicare includes the following services in the global surgery payment when provided:
- Preoperative visits after the decision is made to operate. For ocular surgery and other major procedures, this includes preoperative visits the day before the day of surgery.
- Intraoperative services that are normally a usual and necessary part of a surgical procedure
- All additional medical or surgical services required of the surgeon during the postoperative period because of complications which do not require additional trips to the operating room
- Follow-up visits during the postoperative period of the surgery related to the surgery
- Postoperative pain management services
- Supplies, except for those identified as exclusions
- Miscellaneous services such as dressing changes, local incision care, removal of sutures, etc.
When the operating ophthalmologist determines that it is clinically appropriate to share postoperative co-management services with another practitioner, and the patient provides written consent, Medicare claims for these services must be correctly submitted by both practitioners providing services. Claims for ocular surgery where postoperative care is transferred to another practitioner or provided as co-managed services, must be submitted with the appropriate modifiers:
- CPT Modifier 54 — surgical care only (submit this modifier when one physician performs a surgical procedure and another provides preoperative and/or postoperative management)
- CPT Modifier 55 — postoperative management only (use this modifier to indicate that payment for the postoperative care is split between two or more physicians where the physicians agree on the transfer of postoperative care)
Note: If the surgeon ophthalmologist performs the entire postoperative care, a subsequent referral of the patient to the optometrist for a postoperative refraction and glasses does not constitute co-management. In these instances, only the refraction can be billed to the patient as no ophthalmologic exam is medically necessary and will be denied as unreasonable and unnecessary.
Ophthalmologists performing ocular surgery and providing partial follow up (postoperative) care during the global period of a surgery must submit the claim with at least the following detail lines:
- Submit the surgery with CPT modifier 54 (surgical care only) and the laterality HCPCS modifier RT or LT on one detail line. If surgery was performed bilaterally and is valid for CPT modifier 50, submit the surgery with CPT modifiers 54 and 50 on one detail line, in lieu of submitting CPT modifier 54 with RT or LT on separate detail lines.
- On a separate detail line submit the surgery date as the date of service, the surgery code with CPT modifier 55 (postoperative management only), the laterality HCPCS modifier RT or LT, and the number of postoperative days the patient was under the surgeon's care. If surgery was performed bilaterally and is valid for CPT modifier 50, submit the surgery procedure code with CPT modifiers 55 and 50 on one detail line, in lieu of submitting CPT modifier 55 with RT or LT on separate detail lines.
- The date range during which postoperative care was provided by the surgeon ophthalmologist should be provided in Item 19 (or EMC equivalent) of the CMS-1500 claim form
Optometrists providing postoperative management services must submit the claim with at least the following detail:
- Submit the surgery with the CPT modifier 55 (postoperative management only) and the laterality HCPCS modifier RT or LT on the detail line. Submit the surgery date (not the date on which the postoperative management was assumed) as the date of service. If surgery was performed bilaterally and is valid for CPT modifier 50, submit the surgery procedure code with CPT modifiers 55 and 50 on one detail line, in lieu of submitting CPT modifier 55 with RT and LT on separate detail lines.
- The date on which postoperative care was assumed by the non-surgeon optometrist should be provided in Item 19 (or EMC equivalent) of the CMS-1500 claim form and the number of postoperative days the patient was under the care of the optometrist
Important Reminders Regarding Premium Intraocular Lens (IOL)
The OIG has provided the following guidance in their Advisory Opinion No. 11–14: “Premium IOLs cost significantly more than Conventional IOLs. In addition to the implant itself being more costly, the facility and physician may require additional resources for fitting and inserting the Premium IOL. Additional visual acuity testing may also be necessary in connection with Premium IOLs. The Centers for Medicare & Medicaid Services (CMS) considered how to cover Premium IOLs and ultimately issued two rulings explaining that both the professional fee and the facility fee are partially covered by the Medicare program (CMS-05-01 and CMS-1536-R).
- “Correction of refractive errors does not fall into a covered benefit category.
- “If a Medicare beneficiary elects to receive a Premium IOL rather than a Conventional IOL,
- “Medicare pays for the medically necessary cataract surgery when a Premium IOL is inserted, as well as the covered aspect of the IOL.
- “However, the beneficiary is responsible for the professional and facility fees associated with increased testing and other services related to the correction of refractive errors, as well as the difference in cost between the Premium IOL and the Conventional IOL.”
For more detailed information on correctly billing split postoperative care and accurately reporting CPT modifiers 54 and 55 on claims, visit the Palmetto GBA website: