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Old 10-10-2018, 03:08 PM
ERH ERH started this thread
 
Location: Raleigh-Durham, NC
1,695 posts, read 2,506,660 times
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CPT 66821, Dx H26.492

My dad had cataracts removed from both eyes in 2014 and 2015. He now has to have YAG laser capsulotomy (10/23 and 10/30). The ophthalmologist won't run his insurance until a couple days before the procedure, but I need to figure out what, if any, co-pays he's likely to owe. The insurance clerk gave me the codes (posted above), but usually with an outpatient surgery there are other codes submitted for the facility fee, anesthesia, etc.

I know it's a long shot, but has anyone had this procedure, and if so, was it covered? I seem to remember him paying about $300 out of pocket for one of his cataract surgeries.
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Old 10-10-2018, 03:46 PM
 
Location: SW Florida
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Quote:
Originally Posted by ERH View Post
CPT 66821, Dx H26.492

My dad had cataracts removed from both eyes in 2014 and 2015. He now has to have YAG laser capsulotomy (10/23 and 10/30). The ophthalmologist won't run his insurance until a couple days before the procedure, but I need to figure out what, if any, co-pays he's likely to owe. The insurance clerk gave me the codes (posted above), but usually with an outpatient surgery there are other codes submitted for the facility fee, anesthesia, etc.

I know it's a long shot, but has anyone had this procedure, and if so, was it covered? I seem to remember him paying about $300 out of pocket for one of his cataract surgeries.
This procedure is done quite frequently after cataract surgery to relieve the cloudiness in the vision from the "film" that grows behind, I think it is, where the intraocular lens was placed after the cataract was removed. It's usually a one time procedure which permanently relieves that cloudiness. I had it done on one eye about 1.5 yrs after cataract surgery ( the other eye has never needed it). My mother had it done on both eyes a few months after her cataract surgery and in both our cases the procedure was covered by Medicare.

Assuming the procedure is done by an opthalmologist that accepts Medicare assignment, it's covered under Medicare according to the contract or type of Medicare the patient has, ie, both my mother and I have traditional Medicare Part B with a secondary insurance ( me), or Part B supplemental insurance ( mom) that pays the 20% that Medicare does not pay of the allowed amount, plus any applicable annual deductibles. So neither of us had any out of pocket expenses from either the cataract surgery or the YAG procedure. A patient who has no Part B supplemental insurance will pay the 20% copay not covered by part B Medicare, and a patient who has a Medicare Advantage Plan in which he/she has to pay specified copays for medical services will pay those for both the cataract surgery and Yag procedures. These payments include those billed by the surgeon, the facility, and anesthesiologist if one is used.

https://www.aao.org/eye-health/treat...or-capsulotomy
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Old 10-10-2018, 04:11 PM
ERH ERH started this thread
 
Location: Raleigh-Durham, NC
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Thank you for the detailed response -- I appreciate it!
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Old 10-10-2018, 06:42 PM
 
Location: Wisconsin
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I had this exact procedure in 2016. Medicare approved rates vary by region. Procedure was done at an ambulatory surgical center of a local hospital. Two separate appointments, one for each eye.

Medicare Allowed Charge - Per Eye:

$303.27- Opthalmologist (doc billed $875 per eye)
$433.96 - Surgical Center (hospital billed $3,781.85 per surgery)
$737.23 - Total Medicare Allowed Charge
-589.78 - 80% Medicare Paid
$147.45 - My responsibility

So multiply $147.45 x2 = $294.90 - the copay for both eyes if your father has Original Medicare. Surgical Center charge may differ or not be charged. Some docs do this procedure in their offices, although I understand this is rare.

If he also has a Medigap, most or all of the copay will be paid by the Medigap. Know that the $183 Part B deductible must be satisfied before Medicare begins to pay its 80%, unless he has a Medigap Plan F which will pay the Part B deductible.

If he has an Advantage plan, copays vary by plan.

Last edited by Ariadne22; 10-10-2018 at 07:36 PM..
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Old 10-10-2018, 07:28 PM
ERH ERH started this thread
 
Location: Raleigh-Durham, NC
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Quote:
Originally Posted by Ariadne22 View Post
If he also has a Medigap, most or all of the copay will be paid by the Medigap. Know that the $183 Part B deductible must be satisfied before Medicare begins to pay its 80%, unless he has a Medigap Plan F which will pay the Part B deductible.
Thanks...yes, he has Plan F.
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Old 10-10-2018, 07:36 PM
 
Location: Wisconsin
25,589 posts, read 56,236,996 times
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Originally Posted by ERH View Post
Thanks...yes, he has Plan F.
Well, then, he shouldn't pay anything. Most people who have F's say they never see a bill.
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Old 10-10-2018, 09:21 PM
ERH ERH started this thread
 
Location: Raleigh-Durham, NC
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Quote:
Originally Posted by Ariadne22 View Post
Well, then, he shouldn't pay anything. Most people who have F's say they never see a bill.
Fingers crossed! Thanks.
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Old 03-15-2021, 01:11 PM
 
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What was the outcome of the surgical procedure? I will be having this on one eye in a few weeks.
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Old 03-28-2021, 06:32 PM
ERH ERH started this thread
 
Location: Raleigh-Durham, NC
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His was successful, but I learned recently that my father-in-law's was not.
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Old 03-28-2021, 08:27 PM
 
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I had this procedure done on Friday and my vision is clear in that eye now, except for a few floaters, which I had before and was warned about. I go back in two weeks for a followup. I highly recommend this as it's quick and painless. Medical technology today is amazing.
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