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UPFRONT: Premium Services and the Retina

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The advent of premium intraocular lenses (IOLs) and the gift to cataract surgeons from the Centers for Medicare and Medicaid Services (CMS) in the form of the August 5, 2005 CMS Transmittal 636, which allows surgeons to upcharge patients for these “premium” services and avoid balanced billing issues, has changed the importance of a retina evaluation prior to cataract surgery. In the past, the idea of getting retina involved early to help with the decision on type of lens used during cataract surgery was not considered important, because if there was a pre-existing retina issue such as an epiretinal membrane or age-related macular degeneration, we would simply take care of it after the cataract surgery. Now, the onus is on the cataract surgeon to make sure the patient is a candidate for a premium IOL.

The CMS decision stated that Medicare would pay for the cataract surgery and the inserted IOL (including the extra $50 a facility received for new technology IOLs), and the patient would pay for the “added” benefit of the premium IOL’s ability to correct presbyopia or astigmatism. Baked in to the cost of the premium IOL is the cataract surgeon spending extra time to determine the appropriate lens and to ensure that the patient is a good candidate. This led to cataract surgeons referring patients undergoing premium IOL placement to make sure they have a good retina exam prior to surgery. But as the number of patients undergoing this surgery has dramatically increased, cataract surgeons began obtaining their own optical coherence tomography (OCT) scans to rule out retinal pathology that may affect the cataract surgery outcome. A host of courses on interpreting these OCT images have popped up at the major cataract meetings. An article in this issue describes using ffERG for patients where the cataract is so dense that a view of the retina cannot be obtained to rule out macular pathology. The idea is interesting, but certainly, as the author points out, sometimes the patient may have to cover the cost of the test when nothing is found to justify the test. Moreover, if the lens is so dense that it requires ffERG, should a premium IOL even be considered?

A philosophical question to ponder is whether the idea of premium services can apply to retina practice. For example, we know that OCT angiography will never be reimbursed at a rate greater than conventional OCT, despite the massive increase in diagnostic potential it offers. Can an argument be made for the government to pay for the OCT and for the patient to pay for the benefit of additional diagnosis that retina specialists can make and not having to get a fluorescein injection? Optometrists use the rationale of documenting the entire eye to get wide-field photos of every patient. Alternately, could we charge extra if we use intraoperative OCT to improve our macular surgery outcomes? I know this is an argument that we will never win, but it is nice to dream! RP

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