Cataract Co-Management:
Coding & Billing Guide
Site of Care CPT
®
Code
Surgery for treatment
of cataract, physician
66982, 66984
Surgery for treatment
of cataract, facility
66982, 66984
About Co-Management
With today’s multidisciplinary care model, Ophthalmologists/
Cataract Surgeons and Optometrists are sharing
postoperative responsibilities of cataract patients.
1
Co-management is dened as the relationship between
an ophthalmologist/cataract surgeon and a non-operating
provider (e.g., an optometrist) for shared responsibility
in the postoperative care. There are various scenarios in
which co-management may be appropriate, such as the
patient is unable to return to the surgeon for follow-up,
the surgeon is unavailable for care, patient preference, or
the patient experiences another illness or complication
that requires intervention by another provider.
1
Transfer of care is dened as a transfer of responsibility
for a patient’s care from one qualied healthcare provider
operating within his/her scope of practice to another
who also operates within his/her scope of practice.
1
The
decision as to when it is medically appropriate for the
patient to be released to the care of the co-manager can
only be determined by the surgeon and the patient. The
specic date of the transfer of care cannot be made before
surgery. The surgeon must have the patient sign a written
agreement to be co-managed. Both the surgeon and the
co-managing provider managing the post-operative care
must retain a copy of the written transfer agreement in the
patient’s medical record.
2
A Transfer of Care Form from the surgeon to the co-
managing Provider should include the following
2
:
• Patient name
• Operative eye
• Nature of operation
• Date of surgery
• Clinical ndings
• Discharge instructions
• Transfer date
However, a transfer of care is not needed if the receiving
Provider is within the same group practice.
Type of Care
Provided
Modier and Notes
Surgical care only -54
• Surgeon must initiate the notication to
Medicare by using modier -54 when
billing for the surgery (e.g., 66984-54)
• The date of service is the date of the
surgical procedure
Post-operative
care
-55
•Co-managing provider bills the same
CPT
code with modier -55 (eg, 66984-
55) for the post-operative care
•Cannot bill for the co-managed care until
at least one service has been furnished
to the patient
Cataract Co-Management Billing and Coding
After surgery, the surgeon submits a claim for the procedure
citing the appropriate CPT
®
code and co-management
modier (-54) on the claim form. This modier is required
to identify the surgical procedure in a co-management
scenario. Once the co-managing provider has provided post-
operative care, he or she submits a claim form citing the
appropriate CPT
®
code and co-management modier (-55),
which indicates post-operative management only, as well as
the date he or she assumed the patient’s postoperative care
(refer to the charts below).
2,3
This information is provided for informational purposes only. It does not constitute legal or reimbursement advice or recommendations regarding
clinical practice. Alcon makes no guarantee that use of this information will result in coverage or payment or prevent disagreement by payers with
regard to billing, coverage, or amount of payment. Alcon encourages providers to submit accurate and appropriate claims for services. It is always the
provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit accurate information, codes, charges,
and modiers for services that are rendered. Coding, coverage, and payment policies are complex and are frequently updated. Alcon recommends that
you consult with your legal counsel, applicable payers’ policies, or reimbursement specialists regarding coding, coverage, and reimbursement.
CMS-1500 Claim Form Completion
for Cataract Co-Management
For surgeons who will provide part of the
post-operative care (refer to example surgical claim
form below)
2,3
:
Example Surgeon’s Claim for Post-operative Care
This information is provided for informational purposes only. It does not constitute legal or reimbursement advice or recommendations regarding
clinical practice. Alcon makes no guarantee that use of this information will result in coverage or payment or prevent disagreement by payers with
regard to billing, coverage, or amount of payment. Alcon encourages providers to submit accurate and appropriate claims for services. It is always the
provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit accurate information, codes, charges,
and modiers for services that are rendered. Coding, coverage, and payment policies are complex and are frequently updated. Alcon recommends that
you consult with your legal counsel, applicable payers’ policies, or reimbursement specialists regarding coding, coverage, and reimbursement.
XXX XXX, MD
H25.11
Assumed Post-Operative Care XX/XX/XXXX relinquished XX/XX/XXXX
XXXXXXXXXX
XX XX XX XX XX XX 11 66984 55 RT A XXX XX 1 XXXXXXXXXX
r Submit a claim for with the CPT
®
surgery code 66984 and co-management modier -54 (e.g., 66984-54)
r Submit a claim for your portion of the post-operative care by submitting a second line item entry on the form for
the same surgery procedure code with the modier -55. Note: For the claim to be accurate, the surgeon needs
to know the date the optometrist assumed responsibility for the remaining post-operative care (transfer date)
r Report the range of dates that post-op care was provided in Item 19 (or EMC equivalent of the CMS-1500 claim
form). Only the range of dates is needed (e.g., 1-11-2020 thru 3-11-2020)
r Indicate a “1” in Item 24G of the claim form (or number of post-op days if required by your Medicare carrier/
contractor)
Example Surgeon’s Claim for Surgical Procedure
XXX XXX, MD
H25.11
XXXXXXXXXX
XX XX XX XX XX XX 24 66984 54 RT A XXX XX 1 XXXXXXXXXX
Surgeons submit 2 claim forms:
• One claim form for surgical procedure
• One claim form for the surgeons portion of the
post-operative care
r Submit a claim to Medicare with the CPT
®
cataract
surgery code (e.g., 66984) and modier -55 (e.g.,
66984-55)
r Date of service is the date of surgery (or the date care
was assumed if indicated by your Medicare carrier/
contractor)
• The date care is assumed must be indicated in
Item 19 (or EMC equivalent of the CMS-1500
claim form)
r Enter a “1” in Item 24G of the CMS-1500 claim form
(or the number of post-op days if indicated by your
Medicare carrier/contractor)
Reimbursement for Post-Operative Services
Medicare
The total post-operative care percentage for ophthalmic
procedures has been set at 20% of the surgical fee
allowance. In cases where more than one provider
furnishes post-operative services, the payment will be
divided between the providers based on the number of
days for which each provider is responsible for furnishing
post-operative care.
1,2
Example Claim for Co-management Post-Operative Care
Commercial or Medicare Advantage
Commercial or Medicare Advantage payers may have
dierent guidelines with regard to co-management, and
some payers may not permit co-management at all.
Contact your commercial payers on how to handle billing
co-management services.
1,2
This information is provided for informational purposes only. It does not constitute legal or reimbursement advice or recommendations regarding
clinical practice. Alcon makes no guarantee that use of this information will result in coverage or payment or prevent disagreement by payers with
regard to billing, coverage, or amount of payment. Alcon encourages providers to submit accurate and appropriate claims for services. It is always the
provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit accurate information, codes, charges,
and modiers for services that are rendered. Coding, coverage, and payment policies are complex and are frequently updated. Alcon recommends that
you consult with your legal counsel, applicable payers’ policies, or reimbursement specialists regarding coding, coverage, and reimbursement.
XXX XXX, OD
H25.11
Assumed Post-Operative Care XX/XX/XXXX relinquished XX/XX/XXXX
XXXXXXXXXX
XX XX XX XX XX XX 11 66984 55 RT A XXX XX 1 XXXXXXXXXX
r Do not use visit codes, ophthalmic, or
evaluation and management for this post-
operative care, as this is the most common billing
error for co-managed services
r Note: If the surgeon provides the entire post-
operative care and directs the patient to their
optometrist for post-operative refraction and
glasses, this does not constitute co-management.
Only the refraction can be billed to the patient.
No ophthalmological examination is medically
necessary, medically justied, or medically
reasonable
For co-managing providers who will provide post-operative care
(refer to example post-operative claim form below)
2,3
:
1. American Academy of Ophthalmology. Comprehensive Guidelines for the Comanagement of Ophthalmic Postoperative Care. September. 7, 2016. https://www.aao.org/ethics-detail/guidelines-co-
management-postoperative-care. Accessed March 30, 2020. 2. Richman H and Wartman R. Cataract Co-Management Billing for Medicare. American Optometric Association. https://www.aoa.org/
Documents/optometric-sta/Articles/Cataract%20Co-Management.pdf. Accessed March 30, 2020. 3. Edgar JD, Vicchrilli SJ. Coding Complex Cataract Surgery With Condence. American Academy of
Ophthalmology website. March 26, 2016. https://www.aao.org/young-ophthalmologists/yo-info/article/coding-complex-cataract-surgery-with-condence. Accessed March 30, 2020. 4. Centers for
Medicare & Medicaid Services. CMS Ruling 05-01. May 3, 2005. https://www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/Downloads/CMSR0501.pdf. Accessed March 30, 2020. 5. Centers for
Medicare & Medicaid Services. CMS Ruling 1536-R. January 22, 2007. https://www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/Downloads/CMS1536R.pdf. Accessed March 30, 2020.
Co-Management of Advanced
Technology Intraocular Lenses
(AT-IOLs)
The Centers for Medicare & Medicaid Services (CMS)
permits providers to bill Medicare beneciaries a
separate charge for refractive non-covered services,
including AT-IOLs for astigmatism-correction or
presbyopia-correction (refer to the table below). As with
conventional cataract surgery, some patients who are
referred by their optometrist or ophthalmologist may
wish to return to their referring provider for some of their
post-operative care for an AT-IOL.
1,4,5
In this instance, both the surgeon and the co-managing
providers may participate in providing the non-covered
services associated with post-operative follow-up care
for AT-IOLs. Both the surgeon and co-managing provider
are encouraged to obtain a signed advance notice of
non-covered services and extra fees associated with AT-
IOL use.
1,4,5
Checklist for Co-Management of Patients
Undergoing Cataract Surgery
1,2,4,5
r For Commercial or Medicare Advantage payers,
conrm policy and reimbursement for co-
management services
r Complete written co-management agreement
between the surgeon and the co-managing provider
to share patient care
r Obtain patient’s written consent and archive
patient’s completed transfer of care agreement
(both providers)
r Cite appropriate co-management modiers on the
claim forms (both providers)
r Conrm accuracy of dates of surgery/follow up care
and date of transfer of care
r For AT-IOL patients, explain to the patient noncovered
services and his/her payment responsibilities
CMS Coverage Guidelines for AT-IOLs
4,5
Site of Care What’s Not Covered Patient’s Responsibility
Physician • Physician’s services attributable to the noncovered
functionality of the AC-IOL and PC-IOL
• Additional physician work and resources required for
insertion, tting, and vision acuity testing
• Payment of charges for the physician services
that exceed the physician charge for insertion
of a conventional IOL
Facility • Astigmatism-correcting or presbyopia-correcting
function of an IOL and any additional resources
required for insertion, tting, and vision acuity testing
• Payment of charges for the facility charges that
exceed the facility charge for insertion of a
conventional IOL, including costs of the IOL and
modest charge for handling
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