Transcript DME Post-op Glasses Claims - Nebraska Optometric Association

DME Post-op Glasses Claims
• What is Medicare DME? Do I want to be a
provider?
• How to sign up to be a DME supplier
• PECOS and Accreditation
• How to file clean DME claims with Noridian
• What surgeon and surgery information must be included
• What three diagnoses are acceptable on a DME claim
• What narrative information is required on all Medicare
post-op claims
• How to file each claim line
• What modifiers are required
• Additional resources available
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What is Medicare DME
• DME: Durable Medical Equipment supplied
to Medicare Recipients
• Wheelchairs
• Oxygen
• Refractive Lenses to replace the missing
crystalline lens of the eye
• Post Cataract surgery
• Congenital absence
• Many, many other items
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Who Manages Medicare DME
• DME Suppliers managed by the National
Supplier Clearinghouse (NSC), currently
administered by PalmettoGBA.
http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7SFLC76127?opendocument
• DME Claims handled by our DME carrier,
Noridian Administrative Services.
https://www.noridianmedicare.com/dme/index.html
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Refractive Lens Coverage
In General, Medicare DME covers…
• Patient with implanted IOL after surgery
• One pair of glasses after each cataract surgery
• One set of contact lenses after each cataract surgery
• Patient without implanted IOL
• Aphakic glasses, replaced when medically necessary
• Aphakic contact lenses, replaced when necessary
• Combinations of the above
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Refractive Lens Coverage
• Noridian web site on coverage of refractive
lenses has two resources regarding eligibility,
restrictions, and coding regulations
• Local Coverage Determination (LCD) [13 pages]
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses_lcd_-_effective_10-1-09.pdf
• Refractive Lens Policy Article
[5 pages]
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses_policy_article_-_effective_10-1-09.pdf
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Noridian LCD on Refractive Lenses
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses_lcd_-_effective_10-1-09.pdf
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Noridian Policy Article on Refractive Lenses
Policy Article Source:
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses_policy_article_-_effective_10-1-09.pdf
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DME Refractive Lens Coding
• What you must have on file before you can
file a claim with Noridian………….
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Before submitting a claim to DME, the
supplier must have on file
• A written order (complete description).
• Must be signed and dated by the treating
physician;
• A properly executed beneficiary
authorization for assigned claims;
• A proper advance beneficiary notice (ABN)
if a covered item is personal preference
(not ordered by the physician)
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DME Written Orders
• DME states a written order must contain:
• Beneficiary’s name and full address
• Complete detailed description of the item
• All options or additional features which will be
billed separately
• Signature of physician (OD or MD)
and date signed
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Order Form:
Quentin Quack OD
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1/1/05
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http://www.cms.hhs.gov/BNI/02_ABN.asp
Before submitting a claim to DME, the
supplier must have on file
• Proof of delivery;
• DME (DMEPOS) Supplier Standards
should be given to patient & duplicate
documented in record.
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Order Form:
Quentin Quack OD
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1/1/05
Medicare DME Supplier Standards
• The Durable Medical Equipment Supplier Standards
must be followed closely by the supplier, and a copy
of the standards must be given to the patient.
•Read them
•Follow them
•Give copy to
patient
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https://www.noridianmedicare.com/dme/enroll/25_standards.html
Medicare DME Supplier Standards
• Standards 6: Be sure to document any warranty coverage.
• Standard 9: Make sure your phone listing matches your information on
your NSC enrollment.
• Standard 12: You must document delivery of Rx, and also explanation of
proper care of Rx.
• Standard 16: A copy of the standards must be given to patient, and you
must document that you have done so.
• Standard 19: Make sure to have a written complaint protocol on hand.
• Standard 20: Keep a copy of complaints
Pp. 8-9. . April 2009
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Before submitting a claim to DME, the
supplier must have on file
• Medical records supporting that the refractive
lenses are necessary to restore vision normally
provided by the natural lens of the eye because the
patient has:
• Pseudophakia (ICD-9 V43.1); or
• Aphakia (ICD-9 379.31); or
• Congenital Aphakia (ICD-9 743.35).
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Basic Rules of DME Coding
• Filing a DME claim with Noridian…the
basics found at:
https://www.noridianmedicare.com/dme/claims/cms1500_08-05_tutorial.html
• Specific Rules for Refractive Lens coding
on following slides…
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DME Claims for Cataract Post-op Glasses
• Box 17 (Name of Referring Physician)
• The surgeon’s name, no abbreviations
• Box 17b (NPI)
• The surgeon’s NPI
• Box 19 (narrative section)
• ? The date of the surgery
• ? Which eye was operated upon
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BOTTOM CMS-1500 Referring Dr. Data
Referring Doctor
“John Smith MD”
Referring Doctor’s
NPI
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BOTTOM CMS-1500 Qualifying Information
Example: Date assumed + date relinquished post-op care
+ # Post-op care days.
Date of Surgery: MMDDYYYY
Eye operated: RT or LT
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DME Claims for Cataract Post-op Glasses
• Box 21 line 1 (diagnosis)
• Usual diagnosis: V43.1 pseudophakia
• Also: 379.31 aphakia, 743.35 cong. aphakia
• Box 24, Line 1, Column A (date of service)
• Date glasses were delivered
• Box 24, Line 1, Column B (location of
service)
• 12 [indicates location of use is at home]
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BOTTOM CMS-1500
Claim lines
V43.1
12
Date of
Delivery
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DME Claims for Cataract Post-op Glasses
• Box 24, Line 1, Column D (CPT code)
• V Codes for materials
• Example: V2020 [frame]
• Example: V2304RT [trifocal lens for right eye…no
spaces or dashes]
• Box 24, Line 1, Column F (charges)
• Your total usual and customary charge for that item
(including customary dispensing fee or markup)
• Box 24, Line 1, Column J
• Supplier’s NPI
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From Noridian LCD
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BOTTOM CMS-1500 Charges/Fee
Data
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V-codes with
modifiers
Usual and
customary fees
charged (based
on “per lens”)
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RT and LT Modifier
• Use RT and LT modifier on all HCPCS
codes except frame codes.
• Lenses
• Tints
• Everything except frame
• Lenses provided bilaterally should use the
RTLT modifier & units of 2.
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V-Codes and Modifiers
• V-codes are the same as used for Medicaid
and other 3rd parties
• Some DME Modifiers are the same as other
3rd Parties
• Some DME Modifiers are unique to DME
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BOTTOM CMS-1500 Service & Materials Supplied
V2750EYGARTLT
2
V2744EYGARTLT
2
V2780EYGARTLT
2
V2784EYGARTLT
2
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BOTTOM CMS-1500 Service & Materials Supplied
V2750EYGART
1
V2750EYGALT
1
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DME Written Orders and
Unique Modifiers
DOCTOR’S ORDER
• Regarding the following lens features…
• V2750 anti-reflective coating
• V2744, V2745 tints (transitions &none-sunglass)
• V2780 oversized lenses
• V2784 polycarbonate lenses (monocular vision)
• DME wants to know..
• Was the extra NEEDED, and ORDERED
• Or, was is a PATIENT PREFERENCE item
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DME Written Orders and
Unique Modifiers
DOCTOR’S ORDER
• If feature is specifically ordered by a physician
(OD or MD)
•
•
•
•
V2750 anti-reflective coating
V2744, V2745 tints (transitions &none-sunglass)
V2780 oversized lenses
V2784 polycarbonate lenses (monocular vision)
• Written order should clearly indicate Dr. ordered
it; claim should indicate by using the KX modifier
• Documentation for the need should be available
on request.
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BOTTOM CMS-1500 Service & Materials Supplied
•V2750KX
•V2744KX
•V2780KX
•V2784KX
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DME Written Orders and
Unique Modifiers
DOCTOR’S ORDER
• If one of the following lens feature is NOT
ordered by a physician but is personal preference
•
•
•
•
V2750 anti-reflective coating
V2744, V2745 tints (transitions &none-sunglass)
V2780 oversized lenses
V2784 polycarbonate lenses (monocular vision)
• Claim should indicate it was personal preference
by using the EY modifier
• ABN (advance beneficiary notice) should be
obtained,
• GA modifier should also then be used.
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BOTTOM CMS-1500 Service & Materials Supplied
•V2750EYGA
•V2744EYGA
•V2780EYGA
•V2784EYGA
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XXXXX
None-Covered Items
• None-covered means NEVER covered
• V2760 Scratch resistant coating
• V2781 Progressive lenses
• V2025 Deluxe frames
• A non-covered item is the patient’s responsibility.
• Use the GY modifier on non-covered items
• Assures that the patient’s Medicare Remittance
Advice states patient is responsible for payment.
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BOTTOM CMS-1500 Service & Materials Supplied
•V2025GY
•V2760GY
•V2781GY
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Deluxe Frames & Lenses
Frames.
• V2020 first line of claim.
• V2025 second line of claim.
• The dollar amount for V2025 should be the
difference between U&C deluxe charge and
standard frame charges.
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Deluxe Frames & Lenses
Frame Example.
• Deluxe Frame U&C $150.
• DME Allowed for basic frame $59.58.
https://www.noridianmedicare.com/dme/fees/index.html
• Difference for V2025 is $90.42.
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BOTTOM CMS-1500 Service & Materials Supplied
V2020
5200
V2025GY
9800
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Progressive Lenses
• V2200-V2299 first line of claim (Bifocal
codes), or
• V2300-V2399 first line of claim (Trifocal
codes)
• V2781 next line of claim
• The dollar amount for V2781 should be the
difference between the first line of claim
and your U&C progressive charge
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Progressive Lenses
• EXAMPLE:
• V2203 bifocal pays $47 per lens ($94)
https://www.noridianmedicare.com/dme/fees/index.html
• U&C for Progressive in your office $300
• V2781 equals $206
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BOTTOM CMS-1500 Service & Materials Supplied
V2203RTLT
V2781GY
9400 2
20600 2
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UV Protection
• Covered on Glass lens
• Covered on Plastic if less than 100% UV
protection
• Document type of plastic lens used,
• Document less 100% UV protection.
• Maintain a table of various plastic lenses w/
UVA & UVB protection.
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UV Protection
• Every DME patient record should contain
• Their lab invoice listing the type of plastic lens
supplied
• A copy of table with the lens type circled &
UVA and UVB protection
• This protocol is not in LCD; Presented at a DME
workshop in Omaha
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BOTTOM CMS-1500 Service & Materials Supplied
•V2755KX
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Filing two claims for the same DME
patient prescription
• All items ordered by the physician are filed on
one claim, with the referring physician’s name
and NPI being listed in box 17 and 17b.
• All none-covered items and personal preference
items are filed on a separate claim (at the same
time), with the box 17 and 17b containing the
DME supplier’s name and NPI.
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KX, EY, and GA Modifiers
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KX, EY, and GA Modifiers
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Pg.9. August 2009
References
• Noridian is our DME MAC Durable Medical
Equipment (DME) Medicare Administrative
Contractor (MAC)
• NAS: Noridian Administrative Services, LLC
• https://www.noridianmedicare.com/dme/index.html
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References
• NAS DME Supplier Manual
• Documentation required
– Written order
– Proof of Delivery
– ABN
– Supplier Standards
• Claims Submission
• V-codes
• Pricing
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References
• DME Happenings
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•
•
•
•
•
•
DME Carrier newsletter
Changes in CMS policy
Updates in coding requirements
Updates on documentation needed
FAQs
Changes in contact information
Changes in Billing Requirements
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https://www.noridianmedicare.com/dme/
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https://www.noridianmedicare.com/dme/
ELECTRONIC CLAIMS:
Noridian CEDI Electronic Data
Interchange Information Bulletins
• If file with Noridian electronically, must go through CEDI
• CEDI Puts out a plethora of bulletins each month
regarding the new common electronic data interchange
• CEDI Will remove providers from database if inactive for
13 months.
https://www.noridianmedicare.com/dme/claims/edi.html
PG.4. February 2009
September 2009
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Recent DME Challenges
• Accreditation
Requires none-degree holding suppliers to obtain
accreditation from official accrediting body
(initial cost $2500; and ~$1000 per year)
• Surety Bonds
Requires some suppliers to obtain a $50,000
surety bond (costs $500-$1500 per year)
• PECOS Medicare Database
Medicare’s database of providers and suppliers.
Must be kept up-to-date by you.
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Accreditation and Surety Bonds
• The DMEPOS surety bond and accreditation
requirements have been the subject of several CMS
bulletins and health care provider trade publication
articles.
• ODs do not need accreditation.
• ODs do need surety bonds in some circumstances
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When Surety Bond is Needed
A DMEPOS surety bond is needed by an ODs if s/he
•
•
•
•
•
Fills outside Medicare post-op RXs w/o exam
Sells any DME other than post-op glasses or CLs
Has an optician that is registered with DME
Filled out their 855S enrollment incorrectly (PECOS)
Their dispensary has a different tax ID number
http://www.palmettogba.com/Palmetto/Providers.nsf/files/suretybondfaqs09102009.pdf/$FIle/suretybondfaqs09102009.pdf
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Medicare PECOS Database
• To Avoid Claim Denial, Make Sure that
You, and All Providers that Refer to You,
Are In the Medicare PECOS System
http://nebraska.aoa.org/prebuilt/noa/2009-11-3RD-PARTY-NEWLSETTER.pdf61
Online PECOS
• You must have updated your PECOS enrollment since 2003
• If a referral or an order is involved in any claim, both PECOS
enrollments (“referred by” Dr. and “referred to” Dr.) must be
updated and correct.
• According to CMS, physicians can use
https://pecos.cms.hhs.gov/pecos/login.do to check whether they are in
PECOS
• As of May, CMS claimed that online enrollment is “twice as fast”
as paper PECOS enrollment. (not for original enrollment,
however.)
http://www.wpsmedicare.com/j5macpartb/publications/communique/current/_files/1009comm.pdf
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PECOS Claim Requirements
• If a referring or ordering provider is included on a DME
claim, (areas 17 & 17b), then:
1. That provider and his/her NPI must be in the PECOS
system;
2. The provider’s name must be in all upper case;
3. Use no abbreviations or nick-names;
4. Do not proceed name with “Dr.”
5. Look for the referrer in PECOS system (available soon)
before providing service.
6. Otherwise, claim will be denied.
And you cannot bill the patient.
http://nebraska.aoa.org/prebuilt/noa/2009-11-3RD-PARTY-NEWLSETTER.pdf63
That’s all, Folks!!
Dr. Quack
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