Mary Pat: Welcome back to Ophthalmology Reimbursed. I'm Mary Pat Johnson.
Rebecca: And I'm Rebecca Greenlaw.
Mary Pat: Today's episode is a little different. Before we jump into our usual discussion of coding and reimbursement, we do have something worth celebrating. It's hard to believe, but it's been a full year since we launched our podcast, Ophthalmology Reimbursed.
Rebecca: When we started this podcast, our goal was simple. We wanted to create another way to connect with the ophthalmology community and have practical conversations about reimbursement and compliance issues we encounter every day. There we are a year later, and that's what we want Ophthalmology Reimbursed to be. So before we talk about anything else today, we really just want to say thank you.
Mary Pat: Yes. Thanks for listening. Thanks for sharing our podcast with your colleagues. As we begin our second year, we're inviting you into the conversation. If there's an issue you'd like us to tackle, please let us know. We're interested in topics such as reimbursement, coding and compliance, or even some operational issues having to do with revenue cycle. We'd love to hear what topics are most helpful to you. We know there's a lot competing for your time, and it really means a lot to us that you choose to spend some of that time with us.
Rebecca: We certainly haven't run out of things to talk about. Over the past year, we've covered fundamentals that continue to generate questions like Modifier 25 and J-Code billing, while also responding to Medicare payment changes, MIPS, RAC audits, TPE reviews, drug billing requirements, and new coverage policies.
Mary Pat: And through all that, we have continued to try looking forward. We've discussed the CPT editorial panel actions and developing codes. We know that staying current is about understanding the rules that exist today, as well as watching for what's coming next, to help our practices and ASCs prepare for it.
Rebecca: We've had a lot of fun during the first year taking the podcast outside of our usual recording environment. At ASCRS, we had the opportunity to sit down with people from across the industry and talk about some of the technologies and trends shaping ophthalmology.
Mary Pat: We got to cover topics such as patient engagement and automation with the folks at Promptly. We discussed an interventional glaucoma, specifically the iDose-TR, with some representatives from Glaukos.
And Alcon joined us to talk about photobiomodulation. In our recent summer series, Beyond the Bundle, we were joined by executives from Ocular Therapeutics to discuss Dextenza. They shared their perspective on reimbursement and post-op medication strategies.
Rebecca: Bringing those different perspectives into the podcast is something we'd like to continue into year two.
Mary Pat: And speaking of connecting with the ophthalmology community, we're getting ready to attend the Academy of Ophthalmology meeting in New Orleans, and we're bringing Ophthalmology Reimbursed with us. We'll be teaching a few courses while we're at the meeting. We also have time dedicated to meeting clients, both in the meeting rooms and on the exhibit floor, and we look forward to seeing many of you there.
Rebecca: AAO is always a great opportunity for us to hear what's happening across ophthalmology, what practices and ASCs are experiencing, the questions they're asking, and reimbursement challenges that's getting their attention. And many of those conversations end up shaping topics that we bring back to Ophthalmology Reimbursed.
Mary Pat: So if you're going to the meeting and you'd like to schedule time with us, please reach out in advance. If you don't schedule in advance, you can always look for us in the network lounge or on the exhibit hall floor.
Rebecca: Those conversations are one of our favorite parts of AAO. We spend a lot of time talking to you through podcasts and webinars, so it's always nice to have the chance to sit down and actually talk with you.
Mary Pat: We couldn't celebrate our first year without finishing something we started earlier this summer. In our most recent episodes, we explored separate reimbursement in an ASC setting through our Beyond the Bundle Series.
In episode one, we discussed pass-through drugs. In episode two, we looked at other drug reimbursement methodologies, including non-opioid pain management status. Today, we'll conclude that series by moving beyond pharmaceuticals altogether and discuss devices, tissue products, and reimbursement in the ASC.
Rebecca: And this is an important conversation because when you work in an ASC, the question often becomes very practical. What gets paid separately? What is included in my facility payment? And how do I know the difference? So that's where we're going to focus today.
Mary Pat: So let's start with a few definitions. A device and a supply are not necessarily the same thing, and neither term automatically tells you how Medicare is going to handle it in terms of reimbursement. Medicare includes routine supplies, those that are necessary to perform a covered surgical procedure to be part of the facility fee payment. This includes things like anesthesia supplies, medications used in the OR, and other routine materials like gauze, drapes, sutures, et cetera.
Rebecca: Implantable devices are different in concept, but that doesn't mean that the ASC automatically receives a separate line item payment for the device. In many cases, the device cost is incorporated into the payment for the surgical procedure itself. The ASC still doesn't separately bill for Medicare for the implant itself.
Instead, the payment for the procedure is structured to recognize that a substantial portion of the cost is associated with the implanted device.
Mary Pat: That's right. So when you're looking at your EOBs, please don't confuse coverage with payment. Oftentimes, the items and devices are covered, but there is no separate line item payment made by Medicare. It's included as part of the facility fee. Both cataract surgery and MIGS surgery are good ophthalmic examples.
The standard IOL is an implanted device. It's certainly covered, but its reimbursement is part of the facility fee. There is no separate payment. In glaucoma, a stent or implant may be bundled into the facility payment as well. So Medicare is not ignoring the cost of these items. The cost was considered when the ASC facility payments were established.
Aside from the basic IOL or the standard IOL, which we just mentioned is part of the facility fee, those premium lenses do come at a premium cost, and the upgrade features to address astigmatism or perhaps post-surgery presbyopia are considered refractive. Those are non-covered elements of the IOL. So while Medicare still covers the basic lens, the patient may be charged for those upgrade features, and this should be considered when the ASC sets their charge to the patient for the upgrade features.
Rebecca: For corneal surgery, corneal tissue is an important exception to the general bundling rules. CMS guidance recognizes corneal tissue acquisition as a covered ancillary cost that may be paid separately in the ASC setting when it's furnished in connection with a covered surgical procedure. But that's an important distinction. It doesn't mean every tissue product, allograft, or biologic material used in an ASC is separately payable simply because it's tissue-based.
Mary Pat: And not only is corneal tissue based in the ASC, but you do need to watch what procedure code you link it to. Medicare and most other payers will reimburse the tissue when it's used in conjunction with keratoplasty.
Let's move on to retina surgery. Retina surgery does include the use of many products and supplies, but again, payment for most of those is included in the facility payment. Examples include things like retinal gases, perfluorocarbon liquids, I can't say that word, silicone oil, and even scleral buckling materials.
So we don't want to assume that they're separate payment simply because these products have come to you with a significant acquisition cost. While other plans may have a different approach and allow separate payment, Medicare considers those part of the facility fee.
Rebecca: And in glaucoma, shunts, stents, and similar implants are generally incorporated into the facility reimbursement rather than paid as a separate item.
Mary Pat: And finally, things like anesthesia medications, any medication opened and used in the OR, surgical dressings, trays, those are routine supplies and included in the facility payment. An exception exists for drugs and certain biologicals that qualify under a separate payment pathway. We addressed those in our two previous episodes. But before you equate that an expensive drug is separately billable, you really should look at how Medicare classifies these items and how the associated procedure is paid.
Rebecca: We have a timely example of why that distinction matters. The AMA has moved the effective date for several new Category 3 CPT codes to October 1, 2026 rather than waiting for the more typical January 1 implementation date. One of those codes is particularly relevant to ophthalmology, CPT-1084T, Implantation of Scaffolding Allograft to Reinforce the Superchoroidal Space.
Mary Pat: Remember, a new code doesn't automatically mean that there's new payment associated with it. The code gives us a way to describe a service, but the ASC still needs to determine how Medicare and other payers will reimburse that service and how the associated product costs will be treated.
Because this new code, 1084T, is considered Category 3, we know there's no predetermined allowed amount for the physician or the facility. So centers should be prepared for some variation in how payers establish their coverage and payment rules. As of July 2026 edits on the CMS site, this code is not on Medicare's list of procedures that are eligible for ASC payment. Since the code will be inaugurated on October 1, we'll need to look at Q4 edits on the CMS site to see if that's changed.
Rebecca: And the October 1 implementation is a good reminder that we can't assume every meaningful code change arrives on January 1. ASCs may have a much shorter runway to update systems, educate staff, verify payer policies, and understand the financial implications.
Mary Pat: And that brings us to a practical takeaway from today's episode. When considering a new device, a tissue product, or technology for your surgery center, reimbursement shouldn't be an afterthought. Ask yourself or your team about how the procedure is coded, whether it's reimbursed separately or included in the facility fee.
Is the code defined as device-intensive? Device-intensive codes usually lead to a higher ASC fee for the procedure. How does the acquisition cost compare to the expected reimbursement? How are your major commercial payers handling this? And what documentation is required in the record and on the claims?
Rebecca: And don't stop once the first claim gets paid. A paid claim isn't necessarily a correctly paid claim. It's important to look for any differences between expected reimbursement and actual reimbursement. Coding problems, payer processing errors, outdated system configurations, or policy changes can create underpayments that can continue unnoticed because claims aren't actually denying. And that's why monitoring reimbursement after implementation is just as important as evaluating it beforehand.
Mary Pat: And with that, we've reached the end of our Beyond the Bundle series. We've covered a variety of items and the various ways the reimbursement is handled in an ASC setting.
Rebecca: If there's one theme that connects all three episodes, it's this. Separate reimbursement isn't one single program or set of rules. Some items are packaged, some qualify for separate payment, and some procedures receive a facility payment that reflects significant device costs.
The goal isn't to memorize every rule. It's to understand what you're using in your ASC, how it's classified, and how you're actually getting paid for it. And that's really what we hoped to accomplish with the Beyond the Bundle series.
Take a complicated reimbursement topic, break it down into practical pieces, and give you information you can take back to use in your organization. It's also a great example of the kinds of conversations we want to continue having as we move into our second year of Ophthalmology Reimbursed. We'll continue bringing you timely reimbursement and coding updates, industry perspectives, and deeper dives when a topic deserves more than one episode.
We also want to hear from you. If there's a reimbursement, coding, compliance, or operational topic you'd like us to cover, send it our way. Your question may just become a future episode.
Mary Pat: And before we sign off, I'll remind you again, if you are attending the Academy meeting, don't forget to reach out. We'd love to see you there. If your practice or surgery center is looking for help with coding, help with billing audits, or reimbursement reviews, any kind of compliance assessment, chart audits, don't hesitate to contact us. You can reach us by phone at 800-399-6565, or the website is corcoranccg.com.
Rebecca: Here's to another year of conversations and hopefully not as many reimbursement surprises.
Mary Pat: Oh, we can hope. Thanks again for being part of our first year. Thanks for joining us in this Beyond the Bundle series. And as always, thank you for listening to Ophthalmology Reimbursed.
Announcer: Thanks for listening to Ophthalmology Reimbursed, brought to you by Corcoran Consulting Group, the experts in coding, reimbursement, auditing, and education for the ophthalmic community. Be sure to follow and leave a review wherever you listen to podcasts. Until next time, thanks for listening to Ophthalmology Reimbursed.
