Part 6 filing 3 rd party claims
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Part 6 Filing 3 rd Party Claims. Addressing: Medicare DME Supplier Codes and Modifiers Post-op Glasses (one pair per cataract surgery) Post-op Contact Lenses. Disclaimers.

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Part 6 Filing 3 rd Party Claims

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Part 6 filing 3 rd party claims

Part 6Filing 3rd Party Claims

Addressing:

Medicare DME Supplier Codes and Modifiers

Post-op Glasses (one pair per cataract surgery)

Post-op Contact Lenses


Disclaimers

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.


Disclaimer

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 makeno 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.


What is medicare dme

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


Who manages medicare dme

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.


To enroll as a medicare supplier

To Enroll as a Medicare Supplier

http://www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/National%20Supplier%20Clearinghouse


Part 6 filing 3 rd party claims

Our Medicare Supplier Administrative Contractor…

https://www.noridianmedicare.com/dme/coverage/lcd.htm


Part 6 filing 3 rd party claims

Local Coverage Determination Policy Article HCPCS Codes Covered

https://www.noridianmedicare.com/dme/coverage/lcd.htm


Part 6 filing 3 rd party claims

Local Coverage Determination

https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses.htm


Part 6 filing 3 rd party claims

Policy Article

https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses.htm


Cost to become a medicare supplier

Cost to Become a Medicare Supplier

  • To enroll as a supplier: ~$500 every three years

  • Cost of Surety Bond (if needed…)


Dme requirements

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)


When surety bond is needed

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


Outside rx and need for surety bond

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.)


The supplier must have on file

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)


Valid written order that contains

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


Part 6 filing 3 rd party claims

Order Form:

Quentin Quack OD 1/1/05


Authorization form

Authorization Form

  • As found on the CMS-1500, or

  • In-office equivalent, that remains in effect until canceled by patient


Part 6 filing 3 rd party claims

http://www.cms.hhs.gov/BNI/02_ABN.asp


Before submitting a claim to dme the supplier must have on file

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.


Part 6 filing 3 rd party claims

Order Form:

(Proof of Delivery)

Received by _________________ Date __________

Patient Signature

Quentin Quack OD 1/1/05


Medicare dme supplier standards

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


Regarding medical records

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.


Medical records must support the need for refractive lenses as defined by medicare

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. (quasi-prosthesis)


What is covered

What is Covered?

One pair of glasses (lenses and frame) after each cataract surgery.

  • Lenses

    • single vision ($36-$70 per lens)*

    • standard bifocal ($39-$81per lens)*

    • standard trifocal. ($60-$108per lens)*

  • Standard Frames ($61)*

*fees are approximate, current in 2012


Basic rules of dme coding

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…


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Referring Dr. Data

Referring Doctor’s

NPI

Referring Doctor

“JOHN SMITH”


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Qualifying Information

Example: Date assumed + date relinquished post-op care

+ # Post-op care days.

Date of Surgery and RT or LT


Billing reminders

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).


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Claim lines

Primary diagnosis (used by surgeon)

V43.1

2

12

Date of Delivery


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Charges/Fee Data

2

V-codes with modifiers

Usual and customary fees charged (based on “per lens”)


Non covered items

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


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Service & Materials Supplied

PROGRESSIVE ADD V2781 IS DIFFERENCE FROM U&C

  • V2203RTLT 9400 2

  • V2781GY 20600 2


Non covered items1

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


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Service & Materials Supplied

DELUXE FRAME V2025 IS DIFFERENCE FROM U&C

  • V2020 5200

  • V2025GY 9800


Billing reminders1

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.


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Service & Materials Supplied

RTLT FOR BOTH EYES – UNITS OF TWO

  • V2750EYGARTLT 2

  • V2744EYGARTLT 2

  • V2780EYGARTLT 2

  • V2784EYGARTLT 2


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Service & Materials Supplied

RT FOR OD ONLY; LT FOR OS ONLY– UNITS OF ONE

  • V2750EYGART 1

  • V2750EYGALT 1


Claims for special items

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


Billing reminders2

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


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Service & Materials Supplied

KX MODIFIER WHEN ORDERED BY DOCTOR

  • V2750KX

  • V2744KX

  • V2780KX

  • V2784KX


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Service & Materials Supplied

EY MODIFIER WHEN PATIENT PREFERENCE

GA MODIFIER WHEN ABN SIGNED BY PATIENT

  • V2750EYGA

  • V2744EYGA

  • V2780EYGA

  • V2784EYGA


Non covered items2

Non-Covered Items

  • UV coating (V2755) billed with polycarbonate lenses (V2784)

  • Tinted lenses used as sunglasses

    • (V2745) tints

    • (V2744) photochromatic lenses


Non covered items3

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.)


Non covered items4

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


Modifier gy http www wpsmedicare com j5macpartb resources modifiers

Modifier GYhttp://www.wpsmedicare.com/j5macpartb/resources/modifiers/

  • Used to indicate that the item or service is statutorily non-covered (not a Medicare Benefit).

  • Patient is responsible for payment


Part 6 filing 3 rd party claims

BOTTOM CMS-1500 Service & Materials Supplied

GY MODIFIER WHEN NONE COVERED ITEM

  • V2025GY

  • V2760GY

  • V2781GY


Kx ey and ga modifiers

KX, EY, and GA Modifiers

http://nebraska.aoa.org/prebuilt/NOA/2009-08%203RD%20PARTY%20NEWLSETTER.pdf


Kx ey and ga modifiers1

KX, EY, and GA Modifiers

http://nebraska.aoa.org/prebuilt/NOA/2009-08%203RD%20PARTY%20NEWLSETTER.pdf


For true aphakic patients may supply one of the following

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.


Thank you for listening

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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