Aniridia is a rare condition defined as the full or partial absence of the iris. Most often it occurs as a result of a traumatic injury; less often, it is a congenital abnormality. The patient is severely handicapped due to photophobia from too much light. There is a lengthy history of treatments for aniridia, notably tinted contact lenses — the problem being that many patients are contact-lens intolerant. At the present time, the most promising treatment is an iris prosthesis or artificial iris.

The question is, how does reimbursement work?

Q. What are the indications for an artificial iris?

A. An artificial iris is used for treatment of iris defects. It is indicated for use in children and adults for the treatment of full or partial aniridia resulting from congenital aniridia, acquired defects or other conditions associated with full or partial aniridia, such as albinism.

Q. How is it implanted?

A. An artificial iris is cut to a size that will fit into the capsular bag or ciliary sulcus, using a trephine. The surgeon can implant it in addition to or at the same time as most commercially available IOLs, with the exception of active accommodating IOLs. It can be used for either intracapsular, sulcus or suture fixation, depending on pre-existing anatomy and the evolution of the individual patient’s surgical procedure. Furthermore, secondary suture fixation is possible late after the primary procedure in case progressive zonulopathy causes dislocation of the device.

Q. Will Medicare cover an artificial iris and its implantation?

A. Yes. The treatment of aniridia with an FDA-approved device meets the statutory coverage criteria of the Medicare program for “the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” Other third-party payers generally agree with this policy.

Q. What CPT code is used to report the procedure?

A. At present, choices are limited.

• Use 66999 (Unlisted procedure, anterior segment of eye) to report insertion of artificial iris prosthesis in an aphakic or pseudophakic eye
• Use 66982 (Complex cataract) for insertion of artificial iris and concurrent cataract removal and IOL implantation
• In some cases, particularly following trauma, other ophthalmic procedures may be performed concurrently with implantation of an artificial iris, such as: vitrectomy, keratoplasty, McCannel suture or repair of laceration.

Q. How does payment work for the surgeon?

A. For a specific CPT code, such as 66982, the Medicare Physician Fee Schedule (MPFS) applies. For a miscellaneous code, such as 66999, the MPFS does not specify a payment amount and that determination is made by the Medicare Administrative Contractor on a case-by-case basis. The surgeon does not bill for the artificial iris; the ASC or HOPD does. For other third-party payers, prior authorization is usually required; a payment rate can be set at that time.

Q. What is the Medicare payment to the facility?

A. Under the Medicare Outpatient Prospective Payment System (OPPS), 66999 and 66982 are included in a comprehensive ambulatory payment classification, C-APC 5491. Status indicator J1 is assigned, which means there is a single payment for a C-APC. For the HOPD, the allowed amount is $1,917. For an ASC, there is no payment for 66999; $977 is allowed for 66982. Medicare payment rates are only a benchmark; other third-party payers establish their own rates.

Q. What about the prosthetic device itself?

A. The ASC or HOPD will use HCPCS C1889 (Implantable/insertable device, not otherwise classified) to identify this supply. At the present time, this prosthetic device has no unique HCPCS code. On the UB-04 claim form, use revenue code 278 (other implant).

There is no separate payment for the artificial iris. C1889 is assigned the status indicator “N” in the HOPD, meaning “payment is packaged into payment for other services” and not separately paid. For the ASC, the “N1” indicator is assigned, which means “packaged service/no separate payment made.”

An Advance Beneficiary Notice may not be used to circumvent the OPPS package payment. Other third-party payers make their own payment rules; check with the payer prior to surgery. Prior authorization is strongly recommended, when it is available, including any payment amount for the device. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .