This policy provides direction on correct billing for intraocular lenses (IOL) following cataract surgery.
Three types of intraocular lenses (IOL) are used following cataract surgery:
- Standard or conventional lens
- Astigmatism-correcting intraocular lens (A-C-IOL)
- Presbyopia-correcting intraocular (P-C-IOL) lens
The allowance for the standard or conventional IOL is included in the rate for cataract surgery on the hospital outpatient facility fee schedule and the Enhanced Ambulatory Patient Groups (EAPG) fee schedule.
Lens, intraocular (New Technology)
Anterior chamber intraocular lens
Iris supported intraocular lens
Posterior chamber intraocular lens
Note: C-codes are allowed on UB-04 claims only.
If a member chooses to have an accommodative A-C-IOL or P-C-IOL implanted during cataract surgery, Blue Cross Blue Shield of North Dakota (BCBSND) requires the specific accommodative IOL HCPCS code below billed on revenue code 0276 (Intraocular Lens).
The charges billed for the accommodative IOL HCPCS code must be the difference between the accommodative IOL and the standard IOL charge.
New technology, intraocular lens, category 4 as defined in Federal Register notice
New technology, intraocular lens, category 5 as defined in Federal Register notice
Astigmatism correcting function of intraocular lens
Presbyopia correcting function of intraocular lens
Phakic intraocular lens for correction of refractive error
Lens, intraocular (telescopic)
Any charges reflecting the cost of the standard lens should not be member liable and therefore should not be included in the amount billed for the accommodative IOL HCPCS. The rate for the cataract surgery includes payment for the standard IOL.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
NDBCBS Medical Policy – Intraocular Lens
Additions: Added Limitations and Exclusions statement.
Changes: Standard and accommodative IOLs HCPCS codes listed on prior policy were included in one table. New policy language includes separate tables for standard and accommodative IOL HCPCS codes.
Deletions: Removed member coverage language as this is listed in BCBSND medical policy.
Added CPT code C1840
Made revisions to the policy section to clarify that the allowance for the standard or conventional IOL is included in the rate for cataract surgery.