q & a
Post Cataract Surgery Glasses
Watch for these common billing problems with Medicare optical claims.
By Suzanne Corcoran, C.O.E.
Q When does Medicare cover eyeglasses?
Medicare will cover up to one pair of eyeglasses after cataract surgery with implantation of an intraocular lens. Because Medicare's medical necessity requirement is applicable, the law doesn't guarantee these patients will always receive a pair of glasses following each surgery.
When are two pairs not covered?
If both cataract surgeries are performed within a short period of time and the patient doesn't get glasses following the first surgery, then Medicare will only cover one pair of glasses after the second surgery.
If both cataract surgeries are performed within a short period of time and the patient does get glasses following the first surgery, then he may not need a new frame. In this case, a new lens for the second eye is medically necessary. If the results of the second surgery cause the prescription in the first eye to change, then both lenses are covered.
What are common billing errors, and how should we file these claims?
Claims for postcataract eyeglasses are some of the most complex in all of Medicare. Here are some areas to watch out for on the CMS-1500 claim form:
- If you are the doctor finalizing the prescription, then your name and Unique Provider Identification Number should be in Box 17 and 17a -- not the surgeon's.
- The date(s) of surgery and the operative eye must be noted in Box 19. The carrier doesn't usually require the surgeon's name.
- The most common error on optical claims to Medicare is the date. Remember that Medicare doesn't pay for services before they are performed. Until the glasses are delivered, the service has not been completed. Use the dispensing date as your date of service on the claim.
- Place of service must be the patient's home. Usually this will be Box 12 on the claim.
- Coding for lenses is complex because there are multiple codes for various powers of single vision lenses, bifocals and trifocals -- 14 possible codes for each type of lens! Sometimes the lenses won't be the same code in both eyes, so take care to code each lens separately. The most common error here is coding both lenses the same when one lens contains cylinder and the other does not.
- Watch your modifiers. You need to use RT and/or LT for all lens codes. You must use modifier GA whenever you have the patient sign an Advance Beneficiary Notice because you believe the add on (e.g., tints) won't be covered. Also, the new modifier EY indicates that the add on wasn't ordered by the doctor for medical reasons but the patient chooses to purchase the add on for personal reasons. Modifier EY will cause the claim line to be denied. Bill these modifiers in this order (as applicable):
EY, GA, RT, LT.
- Remember that Medicare requires you to get a signed proof of delivery from the patient. You need an itemized statement of some sort with the patient's signature and date to prove that you did deliver the glasses as your claim states.
- You are required to give the patient a copy of Medicare's Supplier Standards when providing Medicare-covered eyeglasses. If you do not have a current copy, you can download it from the Durable Medical Equipment Regional Carrier Web site.
Sidestep Medicare audits
If you watch out for these common pitfalls, your Medicare claims for postcataract eyeglasses will process more smoothly and you will avoid the risk of refunds in the event of a post-payment audit.
Suzanne Corcoran is vice president of Corcoran
Consulting Group. Reach her at (800) 399-6565 or at SCORCORAN@CORCORANCCG.COM.
Optometric Management, Issue: July 2003