CMS Pub. 100-04, ch. 32, § 120.1

For an IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis,

that is paid under the hospital Outpatient Prospective Payment System (OPPS) or the Inpatient Prospective

Payment System (IPPS), respectively; or in a Medicare-approved ambulatory surgical center (ASC) that is

paid under the ASC fee schedule:

• Medicare does not make separate payment to the hospital or ASC for an IOL inserted subsequent to

extraction of a cataract. Payment for the IOL is packaged into the payment for the surgical cataract

extraction/lens replacement procedure.

• Any person or ASC, who presents or causes to be presented a bill or request for payment for an IOL

inserted during or subsequent to cataract surgery for which payment is made under the ASC fee

schedule, is subject to a civil money penalty.

• For a P-C IOL or A-C IOL inserted subsequent to removal of a cataract in a hospital, on either an

outpatient or inpatient basis, that is paid under the OPPS or the IPPS, respectively; or in a Medicare-approved ASC that is paid under the ASC fee schedule:

• The facility shall bill for the removal of a cataract with insertion of a conventional IOL, regardless of

whether a conventional, P-C IOL, or A-C IOL is inserted. When a beneficiary receives a P-C or A-C

IOL following removal of a cataract, hospitals and ASCs shall report the same CPT code that is used

to report removal of a cataract with insertion of a conventional IOL. Physicians, hospitals and ASCs

may also report an additional HCPCS code, V2788, to indicate any additional charges that accrue

when a P-C IOL or A-C IOL is inserted in lieu of a conventional IOL until January 1, 2008. Effective

for A-C IOL insertion services on or after January 1, 2008, physicians, hospitals and ASCs should use

V2787 to report any additional charges that accrue. On or after January 1, 2008, physicians, hospitals,

and ASCs should continue to report HCPCS code V2788 to indicate any additional charges that accrue

for insertion of a P-C IOL. See Section 120.2 for coding guidelines.

• There is no Medicare benefit category that allows payment of facility charges for services and supplies

required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the facility

charges for services and supplies required for the insertion and adjustment of a conventional IOL.

• There is no Medicare benefit category that allows payment of facility charges for subsequent

treatments, services and supplies required to examine and monitor the beneficiary who receives a P-C

or A-C IOL following removal of a cataract that exceeds the facility charges for subsequent treatments,

services and supplies required to examine and monitor a beneficiary after cataract surgery followed by

insertion of a conventional IOL.

A - For a P-C IOL or A-C IOL inserted in a physician's office

- A physician shall bill for a conventional IOL, regardless of a whether a conventional, P-C IOL, or A-C IOL is inserted (see section 120.2, General Billing Requirements)

- There is no Medicare benefit category that allows payment of physician charges for services and

supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the

physician charges for services and supplies for the insertion and adjustment of a conventional IOL.

- There is no Medicare benefit category that allows payment of physician charges for subsequent

treatments, service and supplies required to examine and monitor a beneficiary following removal of a cataract

with insertion of a P-C or A-C IOL that exceed physician charges for services and supplies to examine and

monitor a beneficiary following removal of a cataract with insertion of a conventional IOL.

B - For a P-C IOL or A-C IOL inserted in a hospital

- A physician may not bill Medicare for a P-C or A-C IOL inserted during a cataract procedure

performed in a hospital setting because the payment for the lens is included in the payment made to the

facility for the surgical procedure.

- There is no Medicare benefit category that allows payment of physician charges for services and

supplies required to insert and adjust a P-C or A-C IOL following removal of a cataract that exceed the

physician charges for services and supplies required for the insertion of a conventional IOL.

C - For a P-C IOL or A-C IOL inserted in an Ambulatory Surgical Center

- Refer to Chapter 14, Section 40.3 for complete guidance on payment for P-C IOL or A-C IOL in

Ambulatory Surgical Centers.