Cataract surgery

Also see: Vision care services

Applies to:

All plans

Priority Health Medicare plans follow Medicare rules for coverage and billing

Definition:

Outpatient surgery to remove a clouded lens of the eye and replace it with an intraocular lens

Billing for cataract surgery & services

Ophthalmologist cataract surgery & services billing

Ophthalmology services are reimbursed at the intraoperative global surgical package percentage. An ophthalmologist who performs the preoperative, intraoperative and postoperative cataract surgery services should bill the global surgery code without any modifiers.

Two ophthalmologists

Use modifiers 54, 55 and 56 on cataract surgery codes only when two ophthalmologists are performing the surgery-related services. Each is paid according to the global split percentages for preoperative, intraoperative and postoperative care.

Preoperative services

Beginning Jan. 1, 2018, the preoperative component will be reimbursed at the intraoperative global surgical package percentage. In the past we have reimbursed for it incorrectly.

Surgical services only

When you perform only the surgical component of the global surgical package, report the services with the CPT code for the cataract surgery and modifier 54.

Claim is reimbursed at the appropriate percentage of the fee schedule for surgical services.

Postoperative services

Priority Health reimburses both optometrists and ophthalmologists for co-management services following cataract surgery for all products.

• When you perform only postoperative services, report them with the CPT code for the cataract surgery and modifier 55.
• List the exact dates you performed postoperative care in the notes section of the claim so we can reimburse surgical and postoperative services rendered by each provider.
• Effective for dates of service on or after January 1, 2018, report postoperative days in units (1 day = 1 unit) to reflect the number of days of postoperative care when postoperative care is split between the ophthalmologist and optometrist providers (not to exceed a total of 90 units).
• Claim is reimbursed at the appropriate percentage of the fee schedule for postoperative care.