Transcript Slide 1

Part 6
Filing 3rd Party Claims
Addressing:
• Medicare DME Supplier Codes and Modifiers
• Post-op Glasses (one pair per cataract
surgery)
• Post-op Contact Lenses
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Disclaimers
This information was prepared by the 3rd Party
Consultant to the Nebraska Optometric
Association, Ed Schneider OD.
To the best of his knowledge, it was current and
accurate at the time it was prepared. It is not
guaranteed to be error or omission free.
It was prepared as general information to assist
doctors and staff, and is not intended to grant
rights or impose obligations.
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Disclaimer
• The ultimate responsibility for the correct
submission of claims and compliance with provider
contracts lies with the provider of services.
• The Nebraska Optometric Association, and its
presenters, agents, consultants and staff make no
representation, warranty, or guarantee that this
presentation and/or its contents are error-free or
omission-free, and will bear no responsibility or
liability for the results or consequences of the
information contained herein.
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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.

DME Claims handled by our DME carrier, Noridian
Administrative Services.
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To Enroll as a Medicare Supplier
http://www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/National%20Supplier%20Clearinghouse
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Our Medicare Supplier Administrative Contractor…
https://www.noridianmedicare.com/dme/coverage/lcd.htm
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Local Coverage Determination
Policy Article
HCPCS Codes Covered
https://www.noridianmedicare.com/dme/coverage/lcd.htm
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Local Coverage Determination
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https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses.htm
Policy Article
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses.htm
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Cost to Become a Medicare Supplier
To enroll as a supplier: ~$500 every three years
 Cost of Surety Bond (if needed…)

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DME Requirements

Accreditation (not needed by ODs)
Requires none-degree holding suppliers to obtain
accreditation from official accrediting body (initial cost
$2500; + ~$1000 per year)

Surety Bonds
Requires some suppliers to obtain a $50,000 surety bond
(costs $500-$1500 per year)
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When Surety Bond is Needed
A DMEPOS surety bond is needed by an ODs if
s/he
•
Sells any DME other than post-op glasses or CLs
•
Has an optician that is registered with DME
•
Filled out their 855S enrollment incorrectly
•
Dispensary has a different tax ID number
•
Fills outside Medicare post-op RXs w/o
established relationship with patient…(more)
http://www.palmettogba.com/Palmetto/Providers.nsf/files/suretybondfaqs09102009.pdf/$FIle/suretybondfaqs09102009.pdf
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Outside Rx and Need for Surety Bond

Written order for your patient by doctor in your office
– You have an established relationship –surety bond not
required by Medicare

Written order by another doctor (surgeon, walk in,
etc.) You must either…
– Purchase surety bond or…
– AOA: Establish a relationship with the patient (check
refraction, acuity, write Rx, document, etc.)
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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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Valid written order that contains:
Beneficiary's name
 Detailed description of the item(s) to be dispensed
 Treating physician's signature
 Date the treating physician signed the order

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Order Form:
Quentin Quack OD
1/1/05
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Authorization Form
As found on the CMS-1500, or
 In-office equivalent, that remains in effect
until canceled by patient

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http://www.cms.hhs.gov/BNI/02_ABN.asp
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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
1/1/05
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Medicare DME Supplier Standards

Applicable Durable Medical Equipment Supplier
Standards must be followed by the supplier, and
a copy given to the patient.
•Read them
•Follow them
•Give a copy to
the patient
https://www.noridianmedicare.com/dme/news/manual/chapter2.html%3f
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Regarding Medical Records…
It is expected that the patient’s medical records will reflect
the need for the care provided.
 These records are not routinely submitted but must be
available upon request.
 Therefore, while it is not a requirement, it is a
recommendation that suppliers obtain and review the
appropriate medical records and maintain a copy in the
beneficiary’s file.

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Medical records must support the need for
refractive lenses as defined by Medicare*
Pseudophakia (ICD-9 V43.1); or
 Aphakia (ICD-9 379.31); or
 Congenital Aphakia (ICD-9 743.35).

*Medicare only covers refractive lenses to restore vision
normally provided by the natural lens of the eye. (quasiprosthesis)
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What is Covered?
One pair of glasses (lenses and frame) after each
cataract surgery.
 Lenses
single vision ($36-$70 per lens)*
standard bifocal ($39-$81 per lens)*
standard trifocal. ($60-$108 per lens)*
 Standard Frames ($61)*
*fees are approximate, current in 2012
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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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BOTTOM CMS-1500 Referring Dr. Data
Referring Doctor
“JOHN SMITH”
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 and RT or LT
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Billing Reminders
One of the following ICD-9 codes that justifies the
need must be included on the claim :
– V43.1 (pseudophakia); (second diagnosis – first
diagnosis is the cataract as per surgeon)
– 379.31(aphakia); (second diagnosis – first diagnosis is
the cataract as per surgeon)
– 743.35 (congenital aphakia).
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BOTTOM CMS-1500
Claim lines
Primary diagnosis (used by surgeon)
V43.1
2
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Date of
Delivery
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BOTTOM CMS-1500 Charges/Fee
Data
2
V-codes with
modifiers
Usual and
customary fees
charged (based
on “per lens”)
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Non-Covered Items
Progressive Lenses V2781

When billing claims for progressive lens, use the
appropriate code for the standard bifocal (V2200-V2299) or
trifocal (V2300-V2399) lens

Add a second line item using code V2781 for the difference
between the charge for the progressive lens and the
standard lens
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BOTTOM CMS-1500 Service & Materials Supplied
V2203RTLT
V2781GY
9400 2
20600 2
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Non-Covered Items
Deluxe Frames V2025

When billing claims for deluxe frames, use code V2020 for
the cost of standard frames

Add a second line item using code V2025 for the difference
between the charges for the deluxe frames and the
standard frames
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BOTTOM CMS-1500 Service & Materials Supplied
V2020
5200
V2025GY
9800
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Billing Reminders

Use the RT and LT modifiers with all HCPCS codes in the
refractive lenses policy with the following exceptions:
– V2020
– V2025

When lenses are provided bilaterally and the same code is
used for both lenses, bill both on the same claim line using
LTRT and two units of service and total charge for both
lenses.
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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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Claims for Special Items
The following special items are covered only if
documented as ordered by the physician (OD or MD)
– Anti-reflective coating (V2750),
– Tints (V2744, V2745) or
– Oversize lenses (V2780)
– Polycarbonate or Trivex (V2784) for the patient with functionally
monocular vision
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Billing Reminders
Anti-reflective coating (V2750)
Tints (V2744, V2745)
Oversized lenses (V2780)
Polycarbonate or Trivex TM (V2784)
for the patient with monocular vision
Add KX modifier for each of these items specifically
ordered by the physician:
Add EY modifier for each of these items provided as a
patient preference:
Add GA modifier on personal preference items after
having patient sight ABN
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BOTTOM CMS-1500 Service & Materials Supplied
•V2750KX
•V2744KX
•V2780KX
•V2784KX
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BOTTOM CMS-1500 Service & Materials Supplied
•V2750EYGA
•V2744EYGA
•V2780EYGA
•V2784EYGA
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Non-Covered Items

UV coating (V2755) billed with polycarbonate
lenses (V2784)

Tinted lenses used as sunglasses
– (V2745) tints
– (V2744) photochromatic lenses
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Non-Covered Items

Polycarbonate (V2784) or high index glass or plastic
(V2782, V2783) for indications such as light weight or
thinness

Scratch resistant coating (V2760),

Mirror coating (V2761),

Polarization (V2762),

Deluxe lens feature (V2702) (e.g., edge tx., etc.)
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Non-Covered Items

Specialty occupational multifocal lenses (V2786)

Hydrophillic soft contact lenses (V2520-V2523) used as a
corneal dressing

Eyeglass cases (V2756)

Low vision aids (V2600-V2615)

Vision supplies, accessories, and/or service components of
another HCPCS vision code (V2797)

Contact lens cleaning solution and normal saline
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Modifier GY
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Used to indicate that the item or service is statutorily noncovered (not a Medicare Benefit).
• Patient is responsible for payment
•
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BOTTOM CMS-1500 Service & Materials Supplied
•V2025GY
•V2760GY
•V2781GY
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KX, EY, and GA Modifiers
http://nebraska.aoa.org/prebuilt/NOA/2009-08%203RD%20PARTY%20NEWLSETTER.pdf
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KX, EY, and GA Modifiers
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http://nebraska.aoa.org/prebuilt/NOA/2009-08%203RD%20PARTY%20NEWLSETTER.pdf
For True aphakic patients, may supply
one of the following…
Bifocal lenses in frames; or
 Lenses in frames for far vision and lenses in frames
for near vision; or
 Contact lenses for far vision and lenses in frames
for near vision worn simultaneously; or
 Contact lenses and lenses in frames worn when the
contacts have been removed.

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Thank You for Listening
We hope this information has been helpful.
Thank you for listening!
See our NOA Website for more 3rd Party
Educational Videos.
3rd Party Services
Nebraska Optometric Association
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