Description:

This policy provides direction on correct billing for intraocular lenses (IOL) following cataract surgery.

Definitions:

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 lens (P-C-IOL)

Policy:

The allowance for the standard or conventional IOL is included in the hospital outpatient facility fee schedule and the Ambulatory Surgical Center (ASC) surgical fee schedule amount for cataract surgery.

Standard Lenses

Note: C-codes are allowed on UB-04 claims only.

Blue Cross Blue Shield of North Dakota (BCBSND) will require the specific IOL HCPCS codes below to be 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. The amount billed on revenue code 0276 will be rejected as member liable.

Accomodative Lenses

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.

Cross Reference:

NDBCBS Medical Policy – Intraocular Lens

History:

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.